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Investigation and inquest
On 20 January 2022, I commenced an investigation into the death of David Christopher Peter Lodge (“Mr Lodge”), aged 40 years. The investigation concluded at the end of the inquest on 20 December 2024. The conclusion of the inquest was Natural Causes contributed to by Neglect.
Box 3 of the Record of Inquest read:
David Christopher Peter Lodge, who had a learning disability, was found on 12 January 2022 unwell next to his deceased carer/father, after having had up to a four day long lie. He was treated at Hull Royal Infirmary, where he was treated for dehydration, and later died on 13 January 2022 from bilateral pneumonia. No chest examination was performed and there was a missed opportunity to transfer to the intensive care unit.
His medical cause of death was recorded as:
1a Bilateral Pneumonia
1b Metabolic Acidosis and Hypovolaemia
1c Dehydration
II Autism, Learning Disability, Dysarthria and Immobility.
Circumstances of the death
Mr Lodge had a learning disability and was cared for by his father, who sadly passed away at their home address. Unable to seek assistance, Mr Lodge endured a long lie by his father’s side for up to four days, before being found by another family member.
He was taken to Hull Royal Infirmary at 12 January 2022 and sadly died mid-morning at 13 January 2022. Mr Lodge was being treated for dehydration and died of bilateral pneumonia.
Whilst at the hospital, Mr Lodge was agitated and, therefore, given sedative medication on two occasions to calm him down in order to permit full observations. Meanwhile, Mr Lodge’s NEWS2 scores were consistently high at 8 or 9 for a number of hours and during that time no chest examination was undertaken.
Intensive care specialists were consulted by the emergency department treating physicians, and no referral eventuated. Mr Lodge was instead, transferred to the acute admissions unit, was not medically assessed again and he later suffered a cardiac arrest and died hours later.
Coroner’s concerns
(1) Pain is not accurately assessed in people who are unable to communicate with words. The court heard evidence that Mr Lodge at no point was provided pain relief, despite requests from the attending family member who was speaking on his behalf. An independent expert, a Consultant in Emergency Medicine, gave evidence that there was no evidence of reasonable adjustments in respect of assessing Mr Lodge’s pain to account for his baseline condition.
(2) Basic examinations, including chest examinations, are not being carried out for learning disabled adults at risk of pneumonia in the emergency department. The treating physicians in evidence agreed that there should have been a high index of suspicion of pneumonia in Mr Lodge’s case and that it is one of the leading causes of death for people with learning disabilities. The court heard evidence that Mr Lodge did not have a chest examination carried out on him due to him not presenting any signs of respiratory distress. The independent expert gave evidence that a thorough examination should have been undertaken and that there was the opportunity to do so after the sedation medication was given.
(3) NEWS2 scores above seven are not appropriately escalated for specialist advice. Clinical recommendations for 30 minute observations were not being followed. An independent expert, a Consultant in Intensive Care, gave evidence to the court that Mr Lodge should have been admitted to the Intensive Care Unit at Hull Royal Infirmary at which Mr Lodge would have undergone closer examinations on a lower patient to nurse ratio.
(4) Opportunities for learning from serious incidents are being lost. No internal investigation or other form of serious incident investigation was undertaken. The court heard evidence from independent experts who opined that it would be expected, following a death in these circumstances, for there to have been an internal review to consider improvements to include input from a specialist with a learning disability team.
Information checked against the published report and official responses