Man with learning disabilities lay next to dead father for days, coroner says

A 40-year-old man with learning disabilities was found lying next to his father up to four days after he died in their home, according to a coroner’s report.

Details of how David Lodge was found seriously dehydrated by his sister were included in a report by Hull and East Yorkshire assistant coroner Edward Steele into lessons which should be learned from his subsequent death in hospital.

In his report, Mr Steele said: “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 (pictured) at January 12 2022 and sadly died mid-morning at January 13 2022.

“Mr Lodge was being treated for dehydration and died of bilateral pneumonia.”

Mr Steele said: “No chest examination was performed and there was a missed opportunity to transfer to the intensive care unit.”

The coroner sent his report to Hull University Teaching Hospitals NHS Trust, NHS England and the Care Quality Commission.

It follows an inquest in December and concluded that Mr Lodge died from “natural causes contributed to by neglect”.

The report included concerns about how pain is not accurately assessed in people who are unable to communicate with words at the hospital and how basic examinations, including chest examinations, are not being carried out for learning disabled adults at risk of pneumonia in the emergency department.

Mr Steele said an independent expert told the inquest that a thorough examination should have been undertaken and that there was the opportunity to do so after sedation medication was given to Mr Lodge, who had become agitated.

He added: “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.”

Following the inquest in December, Mr Lodge’s family said he was born and raised in Hull and was one of three children.

He was born with a learning disability, dysarthria – which meant he could not speak using words – and dyspraxia.

Mr Lodge became registered blind in adulthood and was subsequently diagnosed with autism.

Following a prolonged period in intensive care with pneumonia following dental treatment in 2017, he lost the ability to stand or walk and became a wheelchair user, his family said.

The family said in statement in December: “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.”

A Hull University Teaching Hospitals NHS Trust spokesman 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.”

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