David Lodge
23 Dec 2024 · Coroner Edward Steele · East Riding of Yorkshire and City of Kingston Upon Hull
The coroner's concerns
1. inadequate pain assessment for learning disabled adults
“Pain is not accurately assessed in people who are unable to communicate with words”
2. missed chest examination for at-risk learning disabled adults
“Basic examinations, including chest examinations, are not being carried out for learning disabled adults at risk of pneumonia in the emergency department”
3. inadequate escalation of high NEWS2 scores
“NEWS2 scores above seven are not appropriately escalated for specialist advice”
4. lack of serious incident investigation after death
“Opportunities for learning from serious incidents are being lost”
Responses
2025-0041-Response-from-CQC.pdf ↗· Hull University Teaching Hospitals NHS Trust
Stated action
“We provide the formal response of the Care Quality Commission (CQC) to the Regulation 28 Preventing Future Deaths report made by HM Coroner (Mr Edward Steele, Assistant Coroner) following the inquest into the death of Mr [name redacted].”
2025-0041-Response-from-Humber-Health.pdf ↗· Care Quality Commission
2025-0041-Response-from-NHS-England.pdf ↗· NHS England
Stated action
“NHS England can disseminate the findings from the case of [the deceased] through our network of contacts in health services.”