A recent inquest raised concerns about the treatment of a man who died from natural causes, contributed to by neglect.
The inquest at Hull coroner’s court, presided over by assistant coroner Edward Steele, finished in December.
What happened
On 12 January 2022, Keri Lodge went to visit her brother David and father Peter but neither answered when she knocked on the door and called through the letter box.
She got access to the house with the help of a locksmith, and discovered her father and brother on the floor. Her father had died up to four days earlier. Her brother was still alive, albeit very weak, and was taken by ambulance to Hull Royal Infirmary, where he was admitted at around 4.30pm. His sister went with him to the hospital.
Missed opportunities
The treatment provided at Hull Royal Infirmary was the focus of his inquest. David Lodge died in the early hours of the morning after his admission to hospital.
The coroner found the 40-year-old’s cause of death was pneumonia due to metabolic acidosis (when acid builds up in your body) and hypovolaemia (when your body does not have enough fluid in it) which was caused by dehydration as he had had nothing to drink while lying on the floor at home.
The coroner was told by an independent medical expert it was unlikely he would have survived to leave hospital because he was so poorly when he arrived. However, they said it was likely he would have lived days longer had he been moved to intensive care before midnight.
No lessons have been learned about ensuring adults and children who live at home with a sole carer have a way to get help in an emergency
The coroner found a number of missed opportunities by the hospital and found David Lodge’s death was contributed to by neglect.
The failings of hospital staff included:
- Physical examinations not happening quickly or often enough
- No chest examination
- Fluid treatment insufficiently monitored
- Not admitting him to the intensive care unit or considering this
- Not monitoring him sufficiently after administering sedation.
The coroner said that, had the patient been admitted to intensive care, where there are continuous monitoring and more nursing staff, he would not have experienced a cardiac arrest.
The coroner felt there was still a risk that future deaths would occur at Hull Royal Infirmary unless action was taken, so he issued a prevention of future deaths report (“Reducing risks of further deaths,” winter 2025). This raised four matters of concern:
- Pain not being accurately assessed in people who are unable to communicate with words. Lodge at no point was given pain relief, despite requests from the attending family member who was speaking on his behalf
- Basic examinations, including chest examinations, not being carried out for learning disabled adults at risk of pneumonia in the emergency department
- NEWS2 (National Early Warning Score) scores above 7 were not appropriately escalated for specialist advice. Clinical recommendations for recording observations (these can include heart rate and blood pressure) every 30 minutes were not being followed
- Opportunities for learning from serious incidents were lost. No internal investigation or other form of serious incident investigation was undertaken.
Response still awaited
After the inquest, a spokesperson for Hull University Teaching Hospitals NHS Trust said: “We would like to extend our deepest condolences to the family of Mr Lodge.
“We always try to learn where processes could be improved and will be responding to the coroner in due course.”
Recipients of prevention of future deaths reports are legally required to respond within 56 days; Hull’s deadline was 17 February and the trust had not responded by at time this article was written in late March.
Limits of inquest
The coroner decides how broad an investigation they will conduct – the scope of an inquest. This coroner decided to look at the hospital treatment provided to David Lodge.
The coroner did not investigate support provided to father and son, for example by the local authority. He also did not investigate emergency planning.
The coroner did find that Lodge would have survived if he had been able to summon help shortly after his father died.
Who was David Lodge?
Lodge turned 40 the month before he died, in January 2022, and was the middle of three children. After his parents divorced, he continued to live with his father, Peter.
He enjoyed spending time with his mother, sister, brother and wider family members, lived at home in Hull for his entire life and was a much-loved member of his family.
Lodge had a learning disability and could not communicate verbally. He initially used Makaton at his mainstream primary school where his sister, Keri, says everyone went out of their way to learn to communicate with and include him. Later in life, he used an electronic communication aid.
He loved to go swimming and to the cinema if a film interested him and to shop for DVDs. An expert on children’s television, Lodge had an extensive collection of DVDs, which brought him great joy. He was very knowledgeable about children’s television programmes, enjoyed watching his DVDs and searching for episodes of his favourite programmes on YouTube on an iPad.
David was a person, first and foremost, but that was forgotten by those treating him
His eyesight deteriorated and he was registered blind in adulthood. He was later diagnosed with autism. In 2017, he had dental treatment under sedation that led to aspiration pneumonia and resulted in a lengthy stay in intensive care. After months on a ventilator, he lost the ability to stand or walk and became a wheelchair user.
David’s father, Peter, had a deep understanding of his communication and other needs. He provided him with a safe environment in which distress was minimised.
Keri took an active part in her brother’s life. They would spend Wednesdays together chatting, reading and playing games on the tablet while their father went out.
“I used to tell David that Wednesdays were my favourite day of the week,” she has said.
She would also regularly spend time with him at the weekend, so their father could go out and do shopping, and stay overnight if her father needed sleep.
She had concerns about what might happen in an emergency and recalls discussing this with a social worker at a multidisciplinary meeting.
She had the impression it was assumed her father would get help in an emergency, or she herself would realise something was wrong and arrange help; everyone knew her brother was not able to get to the phone.
‘Findings were shocking’
“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,” Keri notes.
“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.
“While 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.”
