In November the evidence was heard over two days in the inquest of David Lodge, who died on 13 January 2022 at Hull Royal Infirmary.

Today, Assistant Coroner for East Riding of Yorkshire and the City of Kingston upon Hull, Edward Steele, returned to court to give his conclusions.

He opened by expressing his condolences to David’s family, who were joining remotely. Ms Bartlam, the family’s legal counsel, was in court in person. Ms Lyle, legal representative for Hull University Teaching Hospitals NHS Trust was attending remotely.

The coroner apologised that he had been unwell and he was struggling with his voice.

He started by saying on 7 and 8 November he had heard evidence in David’s inquest, but he had insufficient time to properly consider the evidence with a view to drawing out his conclusions at that time. He acknowledged that on both days of David’s inquest proceedings did not finish until after 5pm and he was grateful for those present for facilitating that and sitting beyond normal hours.

He also expressed his gratitude for submissions he had received from David’s family and the trust. He had also sought supplementary opinion from the pathologist Dr Cooke as the two independent court experts had given slightly different views in respect of David’s medical cause of death.

The coroner said whilst there was no legal requirement for him to hear submissions on the Prevention of Future Deaths, it was in his view good practice to do so, and therefore he had.

He asked if there were any matters arising from Interested Persons before he dealt with the evidence and his revised view in relation to inquest conclusions. He turned first to Ms Bartlam.

When she started to address the coroner on the Galbraith Plus threshold test, he interjected to say that it might help if he first indicated his preliminary updated position, before Ms Bartlam continued.

The coroner said that he had revised his view and now intended to give a conclusion that David died from natural causes, contributed to by neglect. He said that Box 3 in the record of inquest would speak to what the neglect was.

Ms Bartlam returned to her submissions, briefly, and when she mentioned Prevention of Future Deaths report, the coroner again suggested that he should indicate his position. This was that he would be issuing a Prevention of Future Deaths report in line with a number of matters raised in the family’s submission to him. This would address four parts.

Ms Lyle for the trust said that the trust had “not much time” to respond to the coroner’s concerns in relation to Prevention of Future Deaths but had sought to do so. She said if the coroner required further information they would request 28 days to provide it.

The coroner thanked the trust for their “comprehensive effort” adding that although “substantively I don’t agree with much of the substance of it”. He said that he would turn to the matters relating to PFDs later, but he would be issuing a Prevention of Future Deaths report and he would not permit a further 28 days to contribute towards that.

Next the supplementary opinion of the pathologist, Dr Justin Cooke, was read onto the record by the Coroner’s Officer, Ms Burns. This said that his deliberations relating to David’s cause of death were “based entirely on morphological features seen at autopsy”. He said the cause of death he had given, bilateral pneumonia was based on “objective evidence seen at autopsy”, and that the alternative causes of death suggested, multi organ failure, acidosis and dehydration, could be due to and associated with severe pneumonia.

The coroner then admitted a statement about Prevention of Future Deaths onto the record of Dr Cherian and Karen Harrison from Hull University Teaching Hospitals NHS Trust. This statement was not read out.

Coroner’s conclusion

He said that he’d then move to his conclusions and would sum up the evidence. He told the court that scope of David’s inquest was in his view reasonable and fair and reminded those present that it was the responsibility of the coroner to set the scope. He reminded himself of previous judgements and guidance relating to inquest practice.

He determined that Article 2 was not engaged on the facts. David’s inquest focused on the care he received at Hull Royal Infirmary. The coroner then proceeded to sum up the evidence he had heard chronologically, finishing with pathology evidence.

He reminded the court who he had heard evidence from: Dr Keri Lodge, David’s sister, from David’s GP, from the paramedic who had attended and from the attending police officer, the pathologist Dr Cooke.

In terms of live evidence, the coroner said on Day 1 he’d heard from Dr Young, Emergency Medicine Consultant and Dr Bailey, Consultant Haematologist. On Day 2 Dr Chase, then a Registrar on Renal and Internal Medicine, and two Independent Experts, Dr Athey and Dr Breen gave evidence.

[I’ll not sum up the evidence again here, for accuracy sake as much as anything, the coroner read at speed, but my original reports of evidence are linked to witness names above].

The coroner outlined a brief chronology of David’s movements within the hospital. He noted within the chronology that there were a number of NEWS2 scores recorded at a level of 9, and that David was transferred from the Emergency Department to the Acute Admissions Unit.

The coroner then outlined the evidence that witnesses had given him, that he had drawn upon in reaching his conclusions.

After the evidence had been summed up court adjourned for a brief break, before the coroner returned to provide his findings of fact.

The coroner said that he made no findings of fact in relation to David’s long lie, adding there was no controversy it had happened “although the length of days is not known, and could not be known” [for anyone coming fresh to this case, David was found lying on the floor next to his father who was also his full time carer and who had died unexpectedly].

The coroner then made 11 findings of fact:

1. An examination of David should have occurred one hour after he was first given sedation at 18:25, but did not in fact occur until 20:53, 2 hours 28 minutes after sedation was given “that was too late”
2. A through chest examination was not undertaken, and should have been, “at least, and if not at then before 9pm”
3. Adequacy of monitoring NEWS2 scores. After the fourth NEWS score of 9 in a row, observations should have taken place half hourly at 23:37 and 00:07 but in fact there was a gap of 1.5 hours. The coroner said he endorsed Dr Young’s position that constituted 2 missed opportunities to take physical observations.
4. Monitoring progress of fluid prescription of 3 litres of Sodium Chloride from 9pm onwards. Dr Chase’s evidence was her expectation was review within 2 hours, by 11pm “that did not happen, I find David’s fluids were insufficiently monitored”
5. Assessment by Intensive Care Specialists. Coroner found David had consistently high NEWS scores and there was no admission to Intensive Care Unit, he was instead transferred to the Acute Admissions Unit and Dr Chase had not known about his admission elsewhere. Coroner found assessment by Intensive Care Specialist should have been considered.
6. Additionally, the coroner found David should have been admitted to the Intensive Care Unit before midnight. He took into account Dr Breen’s opinion that it was not speculation to say by that point [midnight] David was not responding to treatment.
7. Monitoring further sedation medication. Coroner bore in mind that David had a further NEWS score of 8 and was transferred to the Acute Admissions Unit. He found there was “not an appropriate degree of monitoring of David’s position after 00:35 sedation medication was given”.
8. Whether David’s cardiac arrest was preventable? Coroner said he relied heavily on the evidence of Dr Breen that had David been admitted to ICU and therefore had the benefit of continuous monitoring and reduced nurse to patient ratios, it would not have resulted in cardiac arrest.
9. In respect of survivability, the coroner said he adopted the position of the Independent Court Experts Dr Athey and Dr Breen, that
   • David was at a point where he could survive when his father stopped being able to care for him
   • When he arrived at Hull Royal Infirmary it was unlikely he would have survived
   • It is not possible to say at what point in between those two points David would have survived.
10. In respect of prolonging David’s life, contingent to the care provided at Hull Royal Infirmary, the coroner adopted the view of Dr Breen that had David been admitted to the Intensive Care Unit, his life would have been prolonged “by days”.

The coroner’s 11^th finding was David’s cause of death, which was given as:

1a) Bilateral pneumonia

1b) Metabolic acidosis and hyovalemia

1c) Dehydration

2) Learning disability*, autism, dysarthia and immobility

The coroner said that he agreed with the submissions of the family in relation to Part 2 that it was a function of common sense that David would not have contracted pneumonia if he had been able to summon help immediately, and he could not do that due to the matters at Part 2. [*The coroner had said learning difficulty throughout, but when addressed by Ms Bartlam at the end conceded that was a typographic error on his behalf and should of course be learning disability].

The coroner said in Box 3 of the Record of Inquest he would record that David, who had learning disabilities, was found on the 12 January 2022 unwell, next to his deceased carer/father after having up to a 4 days long lie. He was treated at Hull Royal Infirmary for dehydration [missed part] where he later died on 13 January 2022.

No chest examination was performed. There was a missed opportunity to transfer David to the Intensive Care Unit.

In Box 4 he would record that David died from Natural Causes contributed to by Neglect.

The coroner then explained his reasoning for that conclusion, as per the evidence he’d heard, authorities in law, and his thorough examination of the issues of evidence.

He referenced the family’s submissions and said he adopted there submissions in paragraph 8 on the Chief Coroner’s Guidance about balance of probabilities, and paragraphs 16 through to 20 of their submissions, in relation to Bawa-Garba’s Court of Appeal judgement from Sir Brian Levenson in respect of ‘significantly sooner’ and the timing of David’s death.

He said he did not agree in totality with the family’s submissions that David did not receive any part of a response expected in relation to NEWS Scores of over 7. He outlined the facts he said he had made his finding of neglect upon, including in particular:

• There was no chest examination conducted of David after 9pm
• Lack of monitoring of NEWS scores
• Dr Breen’s opinion that by midnight David was failing to respond to treatment and he should have been admitted to the Intensive Care unity by then
• If David had been admitted to ICU he would not have suffered a cardiac arrest
• If David had been admitted to ICU his life would have been prolonged by days.

The coroner said since the inquest hearing on 7 and 8 November he had taken “a lot of time to properly consider this issue”. He said in his preliminary views he was “just on the cusp of considering the rider of neglect did not attach”. At that time he considered “undoubtedly missed opportunities and mischief could be dealt with in a Prevention of Future Deaths report”. He then continued, that as he had come to write his summing up it “had become clear the above facts, in particular, point strongly in the direction of a rider of neglect”.

“The legal test was clearly met and I would be failing in my public duty to not make a finding when found”.

The coroner said he’d considered the submissions of the family and adopted all the additional points they made in paragraphs 13 to 15 as to why he could safely find neglect.

He said Hull University Teaching Hospitals NHS Trust had made submissions that “sought to persuade the court the rider of neglect does not apply in this case”, he said he agreed with their submissions that reference must be made to saving or prolonging life.

He said their submissions spokes to the “analysis of evidence by the writer on the first limb but not the second, the legal test is saving or prolonging”. He added that he respectfully did not agree with their analysis of evidence that had been heard at the inquest in their submissions paragraph 21 and 22.

The coroner said it was his “firm view that there has been no speculation”. He said as coroner he had invited evidence from expert witnesses. He had been clear that he was not receiving speculative answers, as had the family in their questioning.

“Dr Breen and Dr Athey said explicitly when they were trespassing outside areas of their expertise or speculating”.

The coroner reminded the court that the trust had supported Dr Breen being appointed as an independent expert to the court, precisely for the reason of securing critical care expertise about what would have been done if they were consulted.

Dr Breen told the court, that had David been admitted to Intensive Care before his cardiac arrest, he believed it was “probable” that the cardiac arrest would have been avoided.

The family acknowledged in their submissions that the experts had concluded that it was unlikely that David would have survived until discharged, but his life could have been prolonged more than minimally.

The coroner then confirmed what he would be adding in other sections of the Record of Inquest, before turning to the matter of Prevention of Future Deaths.

He said he had provided his preliminary view to Interested Persons in a Case Progression Letter of 28 November 2024. He had considered submissions in writing and orally. He told the court Hull University Teaching Hospitals NHS Trust had submitted a 9 page statement with a number of supporting documents. He had considered carefully their submissions.

“None of my 4 concerns are adequately or sufficiently dealt with, so I maintain my preliminary view”.

The coroner said that he will be issuing a Prevention of Future Deaths Report today, to Hull University Teaching Hospitals NHS Trust, to the Care Quality Commission and to NHS England.

This relates to 4 outstanding matters:

1. Concerns that pain is not being adequately assessed in people who do not communicate with words
2. Basic examinations not being carried out for learning disabled adults at risk of pneumonia in the Emergency Department
3. Concerns that NEWS scores above 7 are not appropriately escalated
4. Opportunities for learning from Serious Incidents are being lost

In relation to adequate pain management of people unable to communicate with words, the coroner said he noted from the trust’s submissions that as recently as April 2024 the pain assessment tool “had low awareness as recently as this year”. He said the trust’s own submissions acknowledged that measures had been brought in so recently there could be no assurances given in relation to whether this was addressed and so it remained a live issue.

In relation to basic examinations the coroner said the trust had responded that they seek to accommodate individuals with a learning disability and/or autism in quieter areas or side rooms, but this “doesn’t adequately or robustly speak to my concern, the concern remains active”.

In relation to concerns about NEWS scores above 7 not being appropriately escalated, the coroner noted the trust’s submission that since the beginning of 2024 they had a consultant or registrar on most shifts on a streaming desk in the Emergency Care area, this is “simply insufficient to speak to this concern”.

In relation to opportunities from Serious Incident Investigations being lost, the coroner noted that:

“Essentially the position of the Trust on these facts as per paragraph 4.1, is that no concerns were raised regarding omissions in care and treatment during the hours David spent at Hull University Teaching Hospitals”.

The coroner said this was the position the Trust had adopted throughout, by Dr Young at the inquest and by a 15 October 2024 statement by Dr Caroline Hibbert.

“Paragraph 5, made only two months ago, she said I can’t see any reason to refer or admit him to the Intensive Care Unit from the Emergency Department”

The coroner said he had also addressed these matters in his Case Progression Letter requesting investigation outputs.

“I am not satisfied the Trust have dealt with these concerns, or their current position is any different from the time of David’s death … this will remain a concern and will go on the Prevention of Future Deaths report”.

Assistant Coroner Edward Steele said he hoped to issue the PFD Report today and that parties would have 56 days to respond.

The coroner concluded the hearing by offering his “double condolences” to David’s family, not just for the loss of David, but also for the loss of Peter, and he commented that he had been very grateful throughout the inquest for Keri’s input.