The death of a man with multiple disabilities that rendered him blind and unable to walk or speak “could have been avoided” with proper hospital care, an inquest has heard.
David Lodge, 40, was found lying on the floor of his home in Hull four days after his father Peter passed away on January 12, 2022.
Davodi, who was born with dysarthia and dyspraxia, leaving him unable to speak or move his limbs normally, was diagnosed with autism and blindness in adulthood and a bout of pneumonia in 2017 also constrained him to a wheelchair.
He moved in with his dad in July 2021, but just months later, was found curled up next to his dead father by emergency workers and died in the hospital himself shortly afterwards.
An inquest into his death has heard that there were numerous failings in his hospital treatment and that he should have been referred to critical care in the Hull Royal Infirmary’s Intensive Care Unit.
After being admitted to the hospital, David was administered fluids and, due to his agitated state, 10mg of midazolam, Hull Live reports.
Nothing further was done until an hour-and-a-half later, when observations of the 40-year-old showed a National Early Warning Score (NEWS) of 9, indicating critical or life-threatening illness.
However, he wasn’t transferred to the infirmary’s Acute Admissions Unit (AAU) until 1am the following morning, four hours later, after being given another sedative, lorazepam. A nurse reportedly thought his symptoms were improving after the admission, but David went into cardiac arrest at 2:49am and, following an end of life care agreement, died later that morning.
An AAU doctor told the inquest that she had been unaware of the lorazepam administration and would have advised against his transfer to the unit had she known. She added that, in her opinion, the sedative had “minimally contributed” to the 40-year-old’s cardiac arrest.
Dr Athey, an emergency medicine expert instructed by David’s family said his movement to the AAU rather than the ICU was the “single most significant omission that may have altered [his] outcome”. He added that David’s treatment had focused on his “social and behavioural” issues rather than his medical state.
Independent critical care expert De Breen concurred, telling the court that the 40-year-old’s life could have been “more than minimally prolonged” had he been admitted to an ICU.
The coroner concluded that his death was contributed to by neglect and issued a prevention of future deaths report to the local NHS Trust.
“David died in the most tragic of circumstances,” Dawn Makepeace, solicitor at Watson Woodhouse Law Firm told Hull Live after the inquest. “His death may well have been avoided if it wasn’t for the failings and multiple missed opportunities by multiple agencies of the state.
“It is unimaginable what David went through in those final days, laid next to his father’s body, unable to help.”
A statement from David’s family added: “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.”
Hull Teaching Hospitals NHS Foundation 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.”