Coroner raises concerns over vulnerable man's death
David Lodge, 40, was found in his Hull home lying next to his carer father, who had himself died a few days earlier.
An inquest in December found that Mr Lodge died of "natural causes contributed to by neglect".
Assistant coroner Edward Steele has written a Prevention of Future Deaths report highlighting issues with Mr Lodge's treatment at Hull Royal Infirmary.
Mr Lodge died on 13 January 2022 from bilateral pneumonia, a day after being admitted to hospital.
In his report, Mr Steele said: "No chest examination was performed and there was a missed opportunity to transfer to the intensive care unit."
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 coroner said that although Mr Lodge was given sedatives, he was not provided with pain relief, despite a family member requesting it.
He also said that "no internal investigation or other form of serious incident investigation" was carried out by the trust following the death.
In a statement, Mr Lodge's family said they hoped the trust would "address some of the ways in which Hull Royal Infirmary failed him once he got to hospital".
They added: "The inquest 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 spokesperson for Hull University Teaching Hospitals NHS 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."
Listen to highlights from Hull and East Yorkshire on BBC Sounds, watch the latest episode of Look North or tell us about a story you think we should be covering here.
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Hull University Teaching Hospitals NHS Trust
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