After lunch on Day 2 of David’s inquest the coroner confirmed that the inquest would not be concluding today as time would not allow to hear from the two remaining witnesses, the court experts, and for the coroner to sum up and conclude.

The final hearing of the inquest will take place on Friday 20 December.

Dr Nicholas Athey was called to give his evidence at 14:17. He gave an affirmation and confirmed that he was a Consultant in Emergency Medicine at South Tees Hospital NHS Foundation Trust.

The coroner said that Dr Athey can provided an expert opinion report, via David’s family, on 6 March 2024. He said he didn’t have cause to take Dr Athey through the facts of the case but asked him to refer to the facts in giving his opion.

The coroner asked him to start by giving his opinion.

NA: Broadly my opinion is there were missed opportunities whilst David was in the ED to refer him for a Critical Care opinion. It wouldn’t have been for the ED team to accept David to Critical Care, was for the Critical Care Team to do that, but there were missed opportunities for that to have occurred. In my opinion that omission was the single largest contributing factor to the outcome.

C: What do you mean by that; forgive me for context you said [he repeats above] assist us with what you mean with that?

NA: That’s at paragraph 3.74 The single most significant omission that may have altered his outcome was a referral to the critical care team. I also highlighted some areas where reasonable adjustments in light of his learning disability and other pre-existing conditions weren’t made.

C: OK, we obviously need to delve into that in a bit more detail and work out the basis on which its formed. You’ve given us your report, section three of it is basically the sub area if I can call it that, you can utilise to generate your opinion and conclusions at 4… does seem sensible to hop scotch at speed, invite you to speak to what the areas are. First is timeliness of interventions

NA: Yes thank you, I’ve highlighted some good practice, there was no major delay in being assessed. The primary clinician involved in his care was a consultant. I would say 6 sets of vital signs were obtained during the approximately eight hours, that there was a delay to the acquisition of a full set of vital signs due to the refusal or inability in obtaining a blood pressure or temperature. I refer to Keri’s statement that it would have been possible to have taken those given his weakened state.

The coroner wishes to explore how Dr Athey reached that conclusion. I missed some of what he said, apologies.

C: Are you opining the opinion of a third person, who is not one of the clinical treating staff?

NA: I am using the opinion of Keri who knew David better than anyone, apart from his father, and I believe that’s in her witness statement

C: I’m just trying to determine, what is the basis upon which you provide that opinion. Where you say in Keri’s statement in her experience would have been possible, you’ve read the statements of practicing clinicians, Dr Young is the one.

I just want to be clear, your opinion there is based on information conveyed to you by a third person, a function of the facts… you’re basing your opinion there on the opinion of a third person, don’t criticise, I recognise what you are doing.

It’s not is it a critical examination of the outputs of the treating clinician Dr Young, you’re employing onto these positions the view of somebody else, albeit Keri?

NA: Yes, I accept that and I acknowledge Keri is also a medical practitioner. I note the Yorkshire Ambulance Crew were able to take a temperature on scene or in the ambulance, but it didn’t seem to be possible to do that in the ED

C: OK, just help us with where you are in your report then?

NA: 3.5

C: OK, so you’re talking about

NA: I go on to note that in the notes there didn’t appear to be any alternative measures attempted to complete this set of observations and NEWS

C reads from report [didn’t catch]

C: Then 3.10 I note that Mr Lodge had not been assessed by a member of AAU medical staff by the time of his cardiopulmonary arrest. You talk about the admission with 4 points, so no issues that flows from the time limited [can’t hear]

NA: Only the lack of reasonable adjustments made in the measurement of temperature and blood pressure

C: What would they look like?

NA: It’s possible to record a temperature from an ancillary measurement, it’s possible to obtain a blood pressure from a leg rather than an arm, that may be less distressing. It’s possible to obtain temperature via no touch technique using infra-red thermometer. I accept all methods have relative benefits and pitfalls, but it is possible to make those observations.

C: What is the authority you refer to in relation to these reasonable adjustments ought to be considered by the practicing professionals?

NA: It should be in the scope of practicing professionals to recognise alternative means exist. It is common to estimate ancillary temperature in the paediatric population for example, so may have been equipment elsewhere in the ED for example

The coroner checks that Dr Athey has no criticism with the time taken to get the initial observations done, but with the lack of reasonable adjustments being made. Dr Athey said that the incomplete observations meant that the original NEWS score was calculated without the inclusion of two parameters.

C: The next sub area is vital signs, just if you can rather than paragraph by paragraph, would it be possible to give global views in relation to this area?

NA: My global view is that the five NEWS values obtained between 20:53 and 00:48 showed a persistent high score, which is a predictor for patients at highest risk of deterioration and that appropriate next steps weren’t taken in answer to that.

C: Help us with how you say appropriate next steps weren’t taken in regards to those NEWS scores please

NA: Yes, certainly. We’ve heard already today a significant volume of fluid was provided… would suggest the persistently elevated NEWS showed no such improvement occurred.

C: The counter view if Dr Young was here, as a function of the evidence I heard him give, if I understood entirely his evidence…. Essentially due to the long lie it would take some time for him to come back up, does that make sense as a question?

NA: It does make sense as a question, but as we heard earlier was degree to which David was dehydrated, his circulatory volume would be deplete to certain amount, the administration of I think 2 litres of IV fluid by midnight should have been adequate to restore that.

C: OK, and your follow through is then appropriate steps, next steps were not taken in light of these NEWS scores. So, what are the steps that would have been appropriate?

NA: This flows on to the issue of whether or not a referral to the Critical Care Team was required in light of that persistently elevated NEWS

C: Help us with that. What’s your opinion?

NA: My opinion is that it was required, not mandated, the wording of NEWS document is it should be considered, and I agree with that, it should have been considered.

C: Your view is required not mandated, working off NEWS document it should be considered. Dr Young said he was, forgive me, chart 4, red box total 7 or more, I remember specifically Dr Young answering one of my questions by referring me to Emergency Assessment Team with Critical Care Competencies and Advanced Airway Management Skills, and I think Dr Young’s evidence is he ticks the box on that bullet point…. Your opinion is it was required not mandated, working off the NEWS document, it should be considered. Help me with that.

NA: Yes, next bullet down says consider transferring care to Level 2 or 3 i.e. Higher Dependency Unit and ICU, both fall in the remit of Critical Care

C: Again the counter argument would be, I’m not asking you to particularise the timeframe on this chronology of where this point occurs. At what point in the chronology are you applying that opinion?

NA: I think we established earlier 2 litres of fluid had been given by around midnight. The first two 500ml amounts were given relatively quickly, by midnight I would say I would have expected an improvement in the condition of David to have occurred.

By that stage we’ve got 4 consecutive very high NEWS, all at 9 points. So, I would say by midnight, or by the time 2 litres of fluids was administered.

C: Your view is once 2 litre of fluids is administered, he’s being treated isn’t he… your evidence is once the 2 litre of fluids has gone through, would your opinion concur with Dr Chase’s evidence at the conclusion at this period should effectively be a re-observation to check where we’re going?

NA: Yes I’d agree with that. I’d also say there should have been a re-evaluation earlier in the time scale as well, and that’s linked to the issue of sedation

C: To extent you do have these NEWS scores, albeit you don’t have document of evaluation at this time, save the nurse who gives the evidence at 01:45, that’s later, we’re much earlier than that, you’re around the midnight juncture aren’t you?

NA: Yes

C: You’re saying he should have been referred to ICU then is that right?

NA: Yes, because that represents the infusion of 4 boluses of 500mls each of intravenous fluids, for a patient who is around 45kg in weight that represents an adequate fluid challenge

C: OK, and in terms of how that referral would occur, help us with what would happen in your opinion?

NA: Would generally be a doctor to doctor referral between an ED clinician with knowledge of the case to, an often registrar in Intensive Care Medicine who has admission or gatekeeping rights to the Intensive Care Units

C: So, Dr Chase gave evidence gatekeeper of the services provided in ICU ward, you recognise the referral would be by your equivalent in the ED, whether or not the referral is accepted is a different thing?

NA: That’s a completely different matter for the intensive care doctor to decide

C: Which I anticipate is why your opinion stops there, because your expertise is in relation to ED?

NA: Absolutely, but the fear of referral not being accepted shouldn’t stop you making referral in the first place. If every patient you refer is admitted to the ICU then you’re not making enough referrals, should be some turned down.

The coroner asks him to explain that more.

NA: If every referral gets accepted, I think that infers you’re missing some referrals

C: Because you expect to be knocked back on some?

NA: Absolutely, for any referral investigation there is an accepted negative rate.

C: What about him, David, going to AAU. What do you say about that in terms of the efficacy of the process there?

NA: It wouldn’t have been appropriate for him to stay in the ED for any longer, he had to go somewhere, respectfully, the issue is if patients persists in the ED for really long periods of time, other people who subsequently become ill in the community cant access ED because people are waiting to get out of ED.

So, it’s absolutely appropriate for him to be transferred to a ward area in the hospital, whether it’s Critical Care or AAU, but if the decision is David is to be admitted to AAU then consideration should have been taken into what is the escalation plan in case of his deterioration.

C: Alright … if he went to AAU he’d still be available to liaise with people in ICU, or have you reached juncture he should have been referred to ITU?

NA: I think we’ve already reached the point where he should have been referred to ITU, if he moved to AAU it wouldn’t be a barrier for his admission later to ITU

The coroner checks that when Dr Athey refers to ITU (Intensive Treatment Unit) he is using it interchangeably with ICU (Intensive Care Unit), he confirms that he is.

NA: Urgency of care, and level of care in nursing ratios, is much less on an AAU than it is on a Critical Care Unit.

C: OK. You mentioned sedation then, is that a topic you want to go onto or clinical assessment?

NA: I’m happy to go wherever

C: Let’s do in order of your report, next is clinical assessment. There existed a missed opportunity, between around 9pm and around midnight, to perform a focussed assessment for injury?

NA: Part of arrival at ED was to conduct a full and thorough investigation, not just control his agitation, was to do a focused assessment. No such detailed clinical assessment ever occurred.

C: The counter position would be I anticipate, am testing your opinion and utilising the alternative medical view given by the medical practitioner… what relevant practitioner is doing, don’t say this is right or wrong, is he’s still in his treatment phase, still being repopulated with fluid, being warmed up. Your opinion is from 9pm on wards, and accept midnight is time he has 2 litres inside him, help us with that juxtaposition

NA: They are two separate things. Treatment with fluids ongoing over couple hours, and the requirement to conduct a full assessment because David had been lying on the floor, potential for him to be injured… and any other co-existing infectious processes

C: By 9 o’clock he’s got 17:32, 18:53 NEWS scores, next one 21:37. Your evidence is from 9 o’clock could have been in position to conduct this clinical assessment. Is there a relationship between this second NEWS score of 9 at time at 20:53, I think it’s 9 o’clock the bloods are taken?’C: By 9oclock he’s got 17:32, 18:53 NEWS scores, next one 21:37. Your evidence is from 9 o’clock could have been in position to conduct this clinical assessment. Is there a relationship between this second NEWS score of 9 at time at 20:53, I think it’s 9 o’clock the bloods are taken?

NA: That’s right, that’s why 9 o’clock point was critical. That’s the time agitation is settled to extent is now possible to establish intravenous access

C: So he’s sufficiently relaxed to take IV, he’s sufficiently relaxed to do assessment of his back, neck, other areas of his body?

NA: That’s the assumption I’ve made yes

C: You’ve said that’s a missed opportunity, between 9pm and midnight, why is that the cut off point?

NA: Because I think that’s about the time David had a second dose of sedation, I’m happy to be corrected?

CB: I can assist on that, is 00:25

C: Anything else you wish to add in relation to clinical assessment?

NA: No, I don’t think so

C: If we go to your next sub-area, blood tests

NA: Apologies sir, just to go back to clinical assessment, phrase in the clinical assessment by Dr Young, for medical admission in any event…. Which suggested to me that Mr Lodge, David was to be admitted to a medical ward, irrespective of the findings of a more detailed assessment

C: Right, OK. In relation to the blood test at paragraph 3.31 help us with your position in relation to this area?

NA: I think blood tests were taken, the tests taken were appropriate, the findings particularly white cell count and CRP were non-specific. Was one finding of elevated CK level… caused by muscle breakdown… suggested a long line … CK contributed to his kidney injury.

C: You get that from the blood results?

NA: From the blood results yes, and I go on to say an assessment of the respiratory system should have been performed to standard, to determine whether or not a chest x-ray should have been taken.

C: When should this have happened?

NA: After the resolution of agitation, around 9pm and before the second peak of agitation around midnight, 20 past midnight

C: Which is when the second sedation is given?

NA: Yes

C: And ok, so that wasn’t done?

NA: It wasn’t done.

I’d have expected the clinician to identify David was at risk of aspiration pneumonia. He’d had it before, he’d had a long lie, he was hypothermic, these are all risks factors.

Really that should have prompted a clinical assessment of the chest, which may have revealed findings that required a chest x-ray

C: [missed start] Who would do the x-ray? Would that be the Emergency Department or ICU?

NA: No, it would be performed within ED, either within the ED if David’s condition was deemed to be too unstable to move out of ED… or might have been acquired in the radiology department, generally speaking located very close to the ED, short transfer from ED to radiology and back to ED

C: So that’s where it should have happened. In terms of what it would have shown… putting some sunlight onto what we know about end result in relation to pathology… what would be the things displayed on x-ray to extent you’re not speculating, and what would happen?

NA: Clearly expected x-ray findings we’d expect to see in bilateral pneumonia, typically consolidation, radiological evidence of infection within the lung tissue

C: OK, if you were in receipt of that output, what would your thought process be?

NA: A malign diagnosis would very much point towards pneumonia and antibiotics are required

C: And just helping me get myself into place I’m comfortable this is process would have happened, or am I asking you stray into speculation? I know what the end position is, saying this is view in whether or not ought to have conducted this… would it have shown these things?

NA: I think we are into speculation, wouldn’t confidently be able to tell you the chest x-ray would be abnormal at that time. Not uncommon for radiological appearance to lag behind the clinical appearances, in other words radiology can be normal with significant pneumonia

But as you say omission of the examination of the chest is the key.

The coroner then asked a question about whether it would be possible to detect pneumonia on physical examination. Dr Athey said it would, that there were characteristic sounds that would be heard if a clinician listened with a stethoscope. He explained the absence of normal lungs sounds, and the detection of course sounds or bronchial breathing would be an indicator.

He told the court that even if the chest x-ray had been normal, the chest examination may have revealed “actors that pointed towards pneumonia and required the administration of antibiotics”.

Next the coroner asked for Dr Athey’s global opinion on sedation.

NA: Sedation was administered initially to control agitation. We know patients with a learning disability may be agitated for a number of reasons, pain, hunger, thirst, fear and there wasn’t any evidence those other features were taken into account or addressed prior to the administration of sedation.

C: OK, so there wasn’t any evidence those other features were taken into account or addressed prior to the administration of sedation, what would be the available opinion… they, pain, hunger, thirst, fear should be taken into account?

NA: In relation to a patient with learning disabilities, before sedation.

C: Dr Young said he was the person who could speak to reasonable adjustments and people with learning difficulties, generally the gist of his evidence. Is there evidence pain, hunger, thirst and fear were not considered in context of sedation medication?

NA: We know David was receiving regular painkillers in the community prior to his hospital attendance, I note throughout his ED stay he wasn’t administered any pain relief. He had underlying chronic conditions such as limb contractures and pressure sores which would have caused chronic pain.

C: In recognition of treating clinicians to recognise those points, hunger and thirst relate to matters arising, he’s had long lie, we can take them. In relation to pain and fear, you cite in fact he had [missed] how would you have sight of that?

NA: Primarily a conversation with David’s sister about his baseline condition and anxiety around leaving the home, and any sort of contact with medical services

C: I think Keri does speak to conversations with ED consultants in relation to these matters and I think Dr Young’s evidence broadly was he was essentially aware of the points you’re speaking to, don’t think is difficult, in relation to sedation being administered initially to control agitation. What’s the efficacy of that position. Isn’t the position of the Trust that they were aware of that?

NA: I think there’s evidence, for example, that David’s pain wasn’t treated whilst he was in ED.

C: Just on that then, sorry every which way you turn I take you on, just need to test the opinion. In NEWS scores there is registration in relation to pain?

NA: Pain isn’t one of the 6 parameters of NEWS but the way its displayed in the Trust print out is it’s in the same table, but pain is not a component of NEWS

C: The point stands doesn’t it, would the Trust say they are effectively registering pain levels. When you say David’s pain wasn’t treated, I’m assuming the evidence I’ve heard is he wasn’t in sufficient pain

NA: It depends on how David’s pain was assessed. Obviously, he wouldn’t have been able to respond to direct questioning about are you in pain, tell me which degree of pain you’re in, can you allocate to number

C: Obviously he wouldn’t have been able to respond to direct questioning

NA: Comes back to reasonable adjustments, are other ways of determining amount of pain people are in. Children are example of this and there are pain scales available for people who are non-verbal

C: Are you saying on evidence, my words, is end place that he was insufficiently tested in way appropriate for someone of his position to properly assess pain?

NA: There is no evidence reasonable adjustments were made when assessing David’s pain to account for his baseline position.

C: Thank you, right, anything else you wish to raise on that?

NA: Yes. The second dose of sedation administered just after midnight, no corresponding re-assessment of David’s condition prior to that dose of intravenous sedation being administered.

You’d expect if David’s agitation had re-emerged, you’d expect some sort of face to face re-assessment to come up with rationale for requiring a repeated dose

C: What you’re saying is it’s a second dose, but you don’t know evidential basis that forms the opinion it should be given?

NA: Correct, and there was no period of enhanced observation after the patient was given the second dose

C: Would you expect it?

NA: Yes. The interval after second dose of sedation is quite risky in terms of increased respiratory depression and [missed]

The coroner then asked a question I missed, apologies.

NA: Midazolam and Lorazepam are both benzodiazepines, and their administration is associated with respiratory depression which could lead to respiratory infection.

C: What about the cardiac arrest, any impact?

NA: Potentially. The administration of these medications can affect the cardiovascular system, but I would caveat that by saying there were other issues also affecting the cardiovascular system, namely the dehydration and the hypothermia

C: Help us with how they’d affect it?

NA: Yes hypothermia, classically causes bradycardia and hypotension, low heart rate, low blood pressure. Dehydration classically causes low blood pressure.

C: OK, I took you down a tangent there, is there anything else in relation to this sub area?

NA: Only other issue with regards to sedation is the lack of any adjustments being made to reflect David’s low body weight

C: Just help us with that then

NA: So, according to the Resuscitation Council Guidelines, guidelines for the resuscitation of children, the resus council say a typical 12 year old weighs 38 kilograms and a typical 14 year old 50 kilos.

So, they don’t stipulate how much they would anticipate a 13 year old to weigh but somewhere between the two. In my estimation David had the approximate body mass of a 13 year old. I don’t think the sedation doses were adjusted accordingly.

C: How so?

NA: 10mg of oral buccal midazolam, midazolam squirted in, would be an appropriate dose in treatment of status epilepticus, in a child of that age.

C: What age

NA: The age of body mass around 45 kg, so around 13

C: OK

NA: But in status epilepticus, which is unrelenting seizures, you’re aiming for a higher degree of sedation as the body is in higher level of arousal to start off with.

I think that is a high dose of Midazolam and likewise would make same observation about the 2mg dose of Lorazepam administered after midnight.

C: Help me out what is your point on this? [He repeats Dr Athey’s last answer] Help me, what’s your point?

NA: The bottom line is David was given sedative drugs at dose appropriate to an average adult weight, but he wasn’t of an average adult weight.

Ms Lyle: I am lost, which paragraph is this?

NA: This isn’t in the report

C: I need to understand what you’re saying here. David was given drugs for average adult weight but he wasn’t an adult weight… you’re essentially saying when they give the sedation medication it was given in ignorance, or lack of cognisance of, his weight being lower than the average person. Is that what you’re saying?

NA: Yes, and its common place in the Emergency Department to adjust drug doses in light of body weight, commonly encountered in frail elderly patients who often have a low body weight.

C: So if giving sedation medication, a consideration is the weight of the person… if bigger they’d need more of a dose?

NA: Yes, these doses administered to David were at the upper end of what I would have administered

C: Explain that

NA: I think a dose of oral Midazolam to achieve sedation in a child would have been less than 10mg, and likewise the initial dose of intravenous Lorazepam to achieve sedation in 45kg child would have been less than 2mgs

C: So you’re saying he was given too much?

NA: Potentially. I’m not saying he wouldn’t have required the doses he was given, but as a starting dose it was potentially too high. Is always better with sedation to start at a lower dose and give more.

C: Right, anything else you want to add?

NA: No, other than that’s another example I think of an adjustment not being made in light of David’s individual circumstances.

C: When you say individual circumstances are you referring to his learning difficulties?

NA: I’m referring to his low body weight

C: So when say his individual circumstances, you mean not individual to David but the patient you have in front of you that happens to be David? Just the patient in front of you?

NA: Yes. Might be for a variety of reasons, frail, elderly, poor nutrition, a number of reasons.

C: Thank you, and your next topic is pain management

NA: I think we may have covered that in roundabout way already

C: Pneumonia and antibiotics

NA: My opinion is blood tests in isolation weren’t enough to indicate antibiotics were necessary, a full focused clinical assessment may have revealed number of indications for antibiotics, it was never made.

C: So you’re saying antibiotics may have been required, but they just don’t know because they didn’t perform a chest x-ray?

NA: Didn’t perform a respiratory system examination, or an abdominal examination, or an examination of the skin or pressure sores which may have revealed an infectious process

The coroner then asked Dr Athey if he would like to comment on the conclusions of the histopathologist. Dr Athey says that he would not with to disagree with him, that he is not an expert in his area and it seams the evidence of bilateral pneumonia is quite compelling at autopsy.

He had nothing further to add about pneumonia or antibiotics. Next they moved to discuss hypothermia.

C: Hypothermia?

NA: My opinion is there’s evidence that David’s cooling was stopped, successfully the cooling process was halted and some evidence later on, I think final observations that rewarming had started. Is evidence in the records that appropriate rewarming methods were undertaken.

C: Anything else about that?

NA: No, thank you

C: Thank you. Events after David left the Emergency Department, you identify here is relationship with matters outside your expertise, help us with this

NA: Covered in part already with discussion about whether it is appropriate to transfer David with a NEWS of 8, my opinion is it was, couldn’t remain in ED indefinitely in anticipation of it falling, but the lack of discussion as to whether he was suitable for an Intensive Care Admission was a significant omission

C: In relation to that, the contact that should have occurred, best interests with Keri, what do you have to say about communications with Keri?

NA: She was present throughout, would have been opportunity to discuss with David and Keri, the issue of escalation, and what’s known as the ceiling of care. In that escalation process, the appropriate ceiling, point at which you won’t escalate any further.

C: Ok.

NA: So there may have been an opportunity to discuss with Keri what David and she would have liked to have happened in the event of a cardiopulmonary arrest, cardiorespiratory arrest.  There would also be an opportunity to determine what degree of invasive procedure was appropriate and would have been wanted.

C: OK, and any other matters in this sort of area?

NA: I don’t think so

C: Equivalence of care

NA: I’ve identified some areas where reasonable adjustments weren’t undertaken. I think we’ve discussed those already

C: Thank you, and prognosis and cause of death already … could you assist us with this area

NA: I think David presented to hospital with some very significant pathology and his ability to recover from that illness, he was already disadvantaged because of his poor physiological reserve, as suggested by his low body weight. So, I go on to say in my opinion his prognosis from this episode of illness was extremely poor.

C: OK, you say there at 3.74 The single most significant omission that may have altered his outcome was a referral to the critical care team. I suppose you sit on the edge of your opinion in saying that, you’d know as ED consultant when someone should be referred to ICU but you can’t give evidence of what would happen within ICU?

NA: Precisely that. I was asked by David’s sister to try and determine the point at which his illness was survivable. I address that at 3.75 in my opinion, had David been able to summon help at the point Peter died and stopped being able to give him care, he’d likely to have survived. Four days later he was at the point where I think he was unlikely to survive, and at some point between those there was a point when he was unlikely, but I’m unable to determine when that point was.

C: To put a different way in the context of the Trust, crude form, is bottom line whatever happened at the Trust in terms of survivability he wouldn’t have survived. Is follow through 4 days later unlikely to survive, you’re not categorically saying. Your evidence is in relation to his attendance at the A&E on 12 January… at that stage your evidence is whatever happened from there on in he was unlikely to survive?

NA: I think that’s correct, unlikely to survive on the balance of probabilities

C: OK, and then you talk about logistical issues in relation to matters outside your expertise, we’ve now dealt with as we instructed Dr Breen. Then you go onto your conclusions.

NA: Yes

C: Help us with that then

NA: These focus on poor physiological reserve, some areas of good practice in terms of the seniority of the doctor that consulted him, and I point out some of the delays encountered, and some of the reasonable adjustments that weren’t made.

C: Thank you, is there anything you wish to emphasise, anything different?

NA: No, I think we’ve covered it already

C: In relation to the 23:37 and 00:07 what put by Ms Bartlam and accepted by Dr Young as missed opportunities

Ms Bartlam offers to explain, and the coroner invites her to do so. She explains that the task sheet on the nursing system required frequency of observations every 30 minutes.

CB: There’s a task sheet in the nursing system, frequency of observations was 30 minutes. All those observations were late, but there was a missed opportunity between 23:07 and 00:10 and that was agreed with, the coroner asked what difference does that make?

C: Yes what is the value of that missed opportunity?

NA: If repeated I’d assume the NEWS would be high and should have acted as a repeated prompt to the clinician David hadn’t responded to the amount of fluid given at that point. As per NEWS recommendations, consideration should have been given to a Critical Care Admission.

C: Thank you, right, I have no further questions.

The court adjourned for a short break, returning at 15:45. It was over to Ms Lyle to ask questions on behalf of Hull University Teaching Hospitals NHS Trust.

SL: Sir, I just have one topic for Dr Athey. It’s on page 19 of your statement, refers to paragraph 4.7 you have referred to it further in your statement but I’ll not refer to that particular point. You are at a disadvantage to a point because you didn’t hear the evidence of Dr Young, but he in his evidence did indicate to the court he was considering David’s weight, and he did take that into account. You indicate it’s unlikely use of sedation contributed to subsequent cardiovascular arrest. Does that remain the same?

NA: That remains my opinion, yes

SL: Thank you

It was then over to Ms Bartlam to ask questions for David’s family.

CB: Yes, I have just a few questions to clarify some points, they’re neatly arranged into 6 topics, very short ones. You said time and time again in your evidence there was no chest examination. We’re talking about someone didn’t go to David’s chest with a stethoscope and listen?

NA: Yes

CB: Would you agree that examination is basic?

NA: Absolutely

CB: Second area is NEWS scores. You’ve clarified what is mandated is the consideration of transfer to ICU, that’s not mandated but continuous monitoring of vital signs is mandated?

NA: Yes, in exactly the part of the document we we’re looking at earlier

CB: In terms of continuous monitoring of vital signs, that’s an inpatient assessment of whether someone is breathing, airway breathing circulation is that right?

NA: It would require the patient to be hooked up to the various monitors and someone to be looking at the monitor

CB: How regularly should someone be looking?

NA: It implies it should be continuous, so all the time

CB: Did that continuous monitoring of vital signs mandated by the Royal College of Physicians happen on the Emergency Department?

NA: No

Ms Lyle: Sir we’ve heard evidence from Dr Young of how that continuous monitoring and the recording of observations is recorded on an electronic system, just wonder whether questioning for this doctor and whether it’s the right way to ask the question as he’s not a factual witness?

C: I recollect me asking Dr Young to entertain the possible distinction between the equipment performing continuous monitoring, and person viewing that output as separate things. Witness was asked did it happen, and answer was no. Your point is whether he can give that evidence?

SL: The evidence so far in this case is he was continuously monitored, hooked up to the monitor, that was the case, but the recordings of those observations was intermittent. I will use that word intermittent, that wasn’t used. So, it’s just the way the question is being put, it’s a factual issue isn’t it

C: Are you suggesting there’s a mischief arising from the question or answer?

SL: Because Mr Athey isn’t a factual witness, he wasn’t present in the hospital, is he able to answer that question whether he was hooked up and monitored continuously? The evidence is he was.

C: Well there’s a distinction… the computer in lieu of a better word is continuously monitoring, monitoring is a disruptive word here unless properly qualified, when we say monitoring, monitoring by a machine is continuous, you used the word intermittent, I agree, being looked at intermittently by a person. Understand the distinction, in relation to how that flows into the question, Ms Bartlam is the point?

CB: To pick up what my learned friend said, is a real issue there, evidence so far is David was hooked up to a machine, so far so good, not contentious. Evidence of Dr Young very properly put to him, he quite proper conceded was only recorded on certain occasions, he couldn’t say what happened in between. Keri’s statement says large periods where left alone.

This witness is asked to comment on the appropriateness of care in the Emergency Department, and there is sufficient evidence for him to form an opinion whether it was appropriate, and in line with the Royal College of Physician guidance.

Sorry I’m not being friendly about this, I don’t think I do need to rephrase the question. I think it’s entirely in this witness’s gift to answer the question.

C: Your question, did continuous monitoring mandated by the Royal College of Physicians, did it happen? The question is a valid question.

The follow through is, is there an evidential basis for the witness to answer that, he’s not a witness of fact, there’s Keri’s evidence, so there is evidence on what can be formed… the expert can opine on factual premise, so I can’t see an issue with respectfully you putting the question and answering, and I think your answer is no?

NA: Correct

CB: Thank you, in terms of the machine would you agree the machine itself can’t measure the totality of someone’s respiratory function?

NA: Absolutely

CB: Yes, to do that would need to be in the room with them?

NA: Yes, counting respiratory rates would need to be done with someone in the room.

CB: You gave evidence of what an x-ray might show, what a chest examination might show, to some extent your conclusion is speculation because the examination wasn’t done. Last observation at 01:20, would you agree any conclusion about what David’s state of health was between 01:20 and his arrest at 03:20 is severely hampered by a lack of observation?

Dr Athey agreed with that suggestion.

CB: Next Lorazepam. You said in your view it was unlikely to have contributed to the arrest. You heard Dr Chase’s evidence earlier on her view on the balance of probabilities was a contributing factor more than minimally, although there were probably other greater factors at play. Would you agree with that view?

NA: It may have been a contributory factor, but I wouldn’t be able to say whether on balance it was likely to have caused the cardiorespiratory arrest

CB: Why do you say that. Is it linked to the lack of observations at that time?

NA: Yes linked to the lack of observations, and last observations relate to normal observations, illogical to see previous sedation affecting on those observations

CB: I put to Dr Chase about plasma levels 2 hours later, would you agree with that?

Dr Athey said he thought peak levels would be achieved earlier than that.

CB: Is it still your opinion the single more important omission in this case was consideration of referral to Critical Care?

NA: Yes. I think that is the omission that would have had the most impact on outcome

Ms Bartlam checks whether that is because there is enhanced monitoring in ICU. Dr Athey responded that there was enhanced monitoring, a better ratio of nurses to patients, and the ability to perform the assessment which up to that point had been lacking.

Ms Bartlam agreed that David’s prognosis was extremely poor, adding that is not contentious. When she asked Dr Athey if he thought David’s life would have been prolonged, even minimally, if he had received care to an appropriate standard, he said he did not wish to step outside his area of expertise as he wasn’t a Critical Care Expert. Ms Bartlam said she would ask that question of Dr Breen.

CB: Finally, medical cause of death, you said had David been able to summon help at the point Peter died, he would likely to have survived. Do you agree part of the difficultly for David summoning help was due to his learning disability, autism, dysarthria and immobility?

NA: I do

CB: Would you agree it is open to the coroner to record underlying conditions of autism, learning disability, dysarthria and immobility?

NA: Yes, and I think that would be reasonable

CB: One very final point about pain and impact, you talked about the need for reasonable adjustments, in terms of David physiological state would you agree could also be extra stress on his respiratory system if he was in pain?

NA: Yes, to an extent

CB: Can you give us an explanation?

NA: Pain is a general stimulus to the body, could cause elevation in his respiratory rate and degree of respiratory distress, if also causing agitation

CB: You said in your report Keri requested pain relief and it was unreasonable in your view not to provide that. Do you agree with that?

NA: I do

Dr Athey was thanked and released at 16:02.