David overcame a lifetime of challenges, not least the attitudes of professionals in health and social care who did not understand that, just because a person cannot speak words, it doesn’t mean they can’t think and feel.

David was the bravest brother, son and uncle, but what he endured in his final days is unimaginable. The inquest’s findings that the care provided to David was so substandard was shocking.

David was a person, first and foremost, but that was forgotten by those treating him.

Whilst I am grateful that the inquest has resulted in four prevention of future deaths reports being issued to Hull Teaching Hospitals NHS Foundation Trust to address some of the ways in which Hull Royal Infirmary failed him once he got to hospital, no lessons have been learned about ensuring adults and children who live at home with a sole carer, such as an older parent, have a way to get help in an emergency.

David deserved better, and we must make sure that nobody else goes through what he did in his last days. David is missed beyond measure.