Vulnerable man died days after concerns raised about nutritional support, inquest told

A man with Down’s syndrome died days after his family had raised concerns about the supposed lack of nutrition he was given at a hospital where he was being treated following a fall, an inquest has heard.

The family of Giuseppe Ulleri (pictured) believe that he went 10 days without being fed during his stay at Manchester Royal Infirmary, where he died from pneumonia after struggling to ingest food through a tube, jurors were told.

Outlining the events leading up to the death, coroner Angharad Davies explained how the 61-year-old’s condition meant that he had difficulty communicating and was not able to take care of himself, meaning he was the subject of a deprivation of liberty safeguarding order.

Jurors heard how, on the morning of February 26 2016, he was found lying on the floor of his bedroom in Withington, Manchester, by staff working for L’Arche, a company who looked after Mr Ulleri and supplied his living accommodation.

Although initial scans taken at Manchester Royal Infirmary that day did not show any significant injuries, he was readmitted the next day after volunteers at L’Arche grew concerned about difficulties he appeared to have in walking and swallowing.

The inquest at Manchester Coroner’s Court heard how an X-ray and CT scan revealed fractures to the vertebrae in his neck, right hip and right wrist.

The coroner explained how, due to the risk of potential pulmonary aspiration, he was made nil by mouth for part of his stay, and had a nasogastric tube, a plastic tube running through the nose and into the stomach, inserted on March 9 2016.

But the coroner explained how the tube only stayed in place for a day, as the patient struggled to use it and felt uncomfortable with it in place.

Ms Davies explained: “Joe had long periods of time when he had no nutritional support when he stayed in hospital, and for a long period the only nutrition he had was that 24 hours when the tube was in place.”

Giving evidence, Mr Ulleri’s brother Peter said he had phoned into a best interests meeting at the hospital on March 16 2016, where it was agreed that a percutaneous endoscopic gastrostomy, where a tube is inserted into the patient’s stomach through the abdominal wall, would take place on March 18.

The witness said he believed his brother’s condition was deteriorating due to lack of sufficient nutrition, and said he told staff: “Why the delay? He could die from this.”

He explained how the delay in giving Mr Ulleri nutrition meant he was too weak to recover from the procedure, and he died on March 20 2016 having suffered from aspiration pneumonia, which occurs when food, stomach acid or saliva is inhaled into the lungs.

Another witness, Sister Christine O’Grady, worked for L’Arche at the time and said she had “grave concern” regarding the perceived lack of pain relief or nutrition Mr Ulleri was given in hospital.

She said that before he was made nil by mouth on March 4 2016, he had started coughing when staff at the Manchester Royal Infirmary attempted to feed him, meaning he had not been properly fed for a considerable amount of time.

Sister O’Grady said to jurors she told a member of staff at the hospital: “If you don’t do anything about it, then I will be seeing you in court.”

Naomi Tomlinson, who was also working for L’Arche at the time of Mr Ulleri’s death, said there seemed to be a lack of “joined-up thinking” at the hospital.

Discussing the communication she had with staff the day before his death, she said: “Within 24 hours, there was a very quick escalation from ‘Joe is not going to die’ to ‘Joe is dying’.”

Giving evidence on Monday, another of Mr Ulleri’s brothers, Giovanni, explained how he had been “an integral part of the family”.

Telling jurors how his brother had been born in Bolton but lived in the south of Manchester for much of his life, he said: “Rather than hide Joe away, mum and dad took him everywhere and were so very proud of him.

“When people stared at him, Joe would throw them one of his smiles and you could not help but smile back at him.

“We’re all deeply in shock that we will never again see his cheeky innocent smile, or feel the tender embrace from one of his hugs.”

The inquest, which is expected to last five days, continues.

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