David Lodge

Care Quality Commission 
Citygate 
Gallowgate 
Newcastle upon Tyne 
NE1 4PA 
Telephone: 0300 061 6161 
www.cqc.org.uk 

HM Coroner 
The Coroners Courts & Office  
The Guildhall  
Alfred Gelder Street  
Kingston upon Hull  

3 February 2025 

Dear HM Coroner (Mr Edward Steele, Assistant Coroner) 

Regulation 28 Report following the inquest into the death of Mr David Christopher Peter 
Lodge. 

We are sorry to hear about the death of Mr Lodge and we offer our sincere condolences to his 
family. 

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 Lodge. (‘the Regulation 28 Report’).  

In the Regulation 28 Preventing Future Deaths report HM Coroner raised the following 
concerns: 

1.  Pain is not accurately assessed in people who are unable to communicate with words. 
The court heard evidence that Mr Lodge at no point was provided pain relief, despite 
requests from the attending family member who was speaking on his behalf.  

2.  Basic  examinations,  including  chest  examinations,  are  not  being  carried  out  for 
learning  disabled  adults  at  risk  of  pneumonia  in  the  emergency  department.  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.  

3.  NEWS2  scores  above  seven  are  not  appropriately  escalated  for  specialist  advice. 

Clinical recommendations for 30-minute observations were not being followed. 

  
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 4.  Opportunities  for  learning  from  serious  incidents  are  being  lost.  No  internal 
investigation  or  other  form  of  serious  incident  investigation  was  undertaken.  This 
regulation 28 report sets out the following matters of concern for CQC to address.  

The trust’s last comprehensive inspection was in November 2022 and the report was 
published in March 2023. CQC rated the trust as “Requires Improvement”. A copy of the 
report can be found on our website - Trust - RWA Hull University Teaching Hospitals 
NHS Trust (23/03/2023) INS2-13905362001 (cqc.org.uk) 

During this inspection serious concerns were identified in Urgent and Emergency Care (UEC) 
that led to the CQC subsequently issuing an urgent enforcement action – Section 31 of the 
Health and Social Care Act 2008.   

The Commission had reasonable cause to believe that any person will or may be exposed to 
the risk of harm arriving from the following: 

• 

• 

• 

The identification and management of deteriorating patients. 

The inability to demonstrate that fundamental standards of care are being met. 

Management of patients waiting within the department. 

Immediate  assurances  were  requested  by  the  CQC  that  the  trust  had  mitigated  the  risks 
identified by 4th of November 2022.  Assurances were provided and accepted by the CQC. 

The  trust  was  required  to  submit  an  action  plan  by  the  8th  of  November  2022  to  indicate 
actions taken and any further steps to be taken to mitigate immediate risks to patient safety 
as identified above.  This action plan was submitted, and accepted, by CQC within the required 
timeframe. 

The trust also provided details of the longer-term actions required to ensure the 
improvements would become sustained and embedded. The CQC continues to closely 
monitor progress against all action plans to ensure sustained improvement through regular 
engagement with the trust. 

In addition to inspection activity the CQC attends a monthly Quality Improvement Group 
(QIG) chaired by NHS England, where the trust presents monthly updates against the CQC 
action plans and key priority areas. The purpose of the QIG is to support planning, 
coordination and facilitate the sustained delivery of actions to mitigate and address the 
quality risks within the trust.  

CQC first became aware of the death of Mr Lodge on receipt of the Regulation 28 Report on 
23 December 2024. 

CQC asked Hull University Teaching Hospitals NHS Trust to provide evidence of any action 
they  had  taken  to  date  following  the  tragic  death  of  Mr  Lodge  and  we  are  waiting  for  their 
response. 

 
 
 
 
 
 
 CQC will continue to closely monitor information we receive about the service. Where CQC 
identifies that regulations are not being met, we will use our enforcement powers to require 
improvements to be made.   

CQC will also check the provider’s compliance with the regulations on our next inspection of 
the service using our new single assessment framework methodology in accordance with the 
CQC regulatory remit.  CQC will highlight any repeated or new breaches of regulation and ask 
them to make necessary improvements.   

CQC’s next inspection of the service is not yet confirmed, however we have adopted a more 
risk-based approach to inspections should CQC receive negative intelligence or have further 
concerns about the service we would carry out responsive inspections.   

CQC hope that this response addresses your concerns.   

Yours sincerely 

Deputy Director of Operations 
North Network

Mr Edward Steele 
Assistant Coroner for Hull & the East Riding of 
Yorkshire 
The Coroner’s Court & Offices 
The Guildhall 
Alfred Gelder Street 
Hull 
HU1 2AA 

14 March 2025 

Dear Mr Steele,  

Hull Royal Infirmary 
Anlaby Road 
Hull 
HU3 2JZ 

Email: 

Re: Hull University Teaching Hospitals NHS Trust response to the Regulation 28 Report issued by 

His Majesty’s Assistant Coroner, Mr Edward Steele, dated, 23 December 2024 

Thank you for sharing your report with us regarding the sad passing of Mr Lodge.  Having considered your 

report carefully the Trust wish to provide a detailed update regarding the work carried out by the Trust 

since January 2022 which will hopefully alleviate any concerns you may have regarding the risk of future 

deaths.  We take the matters raised in your report seriously and we hope this letter is helpful in outlining 

how we are committed to learning. 

The Trust wish to express their sincere condolences to David’s family for their loss of not only David but 

his father Mr Peter Lodge.  

In formulating this response, we have sought opinion from a number of professionals within the Trust.  

Hull University Teaching Hospitals NHS Trust (HUTH) along with North Lincolnshire and Goole NHS FT 

(NLAG) have recently joined forces to create NHS Humber Health Partnership which has brought a wealth 

of expertise together to create structure and improvements to patient safety. The creation of NHS Humber 

Health Partnership has created more structure than ever before.  Various groups from HUTH such as the 

Resuscitation, Deteriorating Patients and Sepsis Steering Group and the NLAG Resuscitation Committee 

have come together to share their knowledge and experiences and created a route of escalation to the  

Working in partnership: 
Hull University Teaching Hospitals NHS Trust 
Northern Lincolnshire and Goole NHS Foundation Trust 

United by Compassion: 
Driving for Excellence. 

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 Quality  and  Safety  Committee.    NHS  Humber  Health  Partnership  follow  the  NHSE  model  of  prevent, 

identify, escalate and respond. 

Since the coming together of the two Trusts a number of key work streams have been created, some of 

which are addressed below, including education, Martha’s Rule, and patient engagement. NHS Humber 

Health Partnership believe that Patient engagement is vital.  Feedback from patients and families is being 

obtained and the information gathered is being used to develop our improvement strategy which will feed 

in to our work around sepsis and deteriorating patients. The Partnership has seen the setup of the Patient 

Engagement Work stream which was a subsidiary group from the Resuscitation, Deteriorating Patient and 

Sepsis Steering Group.   

In addition, the Dementia Volunteers have also been instrumental in helping to gather patient feedback 

and there is a plan in place for the volunteers to assist with gathering feedback from learning disability 

patients and their carers.    

Caring for Patients with Learning Disabilities  

1.  A Mental Health, Learning Disabilities and Autism Steering Group was established in 2020 and 

held bi-monthly meetings chaired by the Assistant Chief Nurse. The group was made up of 

staff  from  all  health  groups,  Training  and  Development,  Patient  Experience,  Allied  Health, 

Dementia  Team,  Mental  Health  Liaison  Team,  Learning  Disabilities  Liaison  Nurse, 

Governance,  Human  Resources,  Information  Services  and  the  Safeguarding  Teams.  The 

group reported to the Trust Patient Experience Sub Committee until the last meeting in July 

2024.  Governance  arrangements  have  now  changed  within  the  new  NHS  Humber  Health 

Partnership and there are now five Operational Groups including, Vulnerabilities, Midwifery, 

Children Safeguarding, Adult Safeguarding and Looked After Children and each group feeds 

in any concerns raised to the Strategic Safeguarding Board.  Following the Coroners Inquest 

the case of David Lodge has been raised and escalated to the Strategic Safeguarding Board. 

2.  In  June  2020,  the  Safeguarding  Adults  team  in  consultation  with  the  Community  Learning 

Disabilities team established a reasonable adjustment admission pathway for David (digitally 

stored on Lorenzo) to ensure his needs were considered and where possible met for all repeat 

attendances at Hull University Teaching Hospitals. 

Working in partnership: 
Hull University Teaching Hospitals NHS Trust 
Northern Lincolnshire and Goole NHS Foundation Trust 

United by Compassion: 
Driving for Excellence. 

 
 
 
 
 
 
 
 
 
 
 
 
 
 3.  From May 2021 to date, Hull Clinical Commissioning Group has commissioned one fulltime 

equivalent  Learning  Disability  Liaison  Nurse  role,  hosted  by  Humber  Teaching  Foundation 

Trust with an honorary contract within Hull University Teaching Hospitals NHS Trust. There 

are posters printed and displayed in the Emergency Department to make staff aware of this 

role  and  the  poster  includes  contact  details  so  the  team  are  able  to  contact  if  support  is 

required.  

4.  The  Learning  Disability  Liaison  Nurse  is  based  within  the  Safeguarding  Adults  team  and 

provides support to patients, carers and their relatives. The Liaison Nurse supports the Trust 

and its clinical staff providing expert specialist advice pertaining to Learning Disabilities; this 

includes structured judgement reviews, patient safety and safeguarding investigations. 

5.  Due to the innovative role, the learning disability liaison nurse straddles acute and secondary 

care so can work closely with family, carers and the community Learning Disability team to 

ensure care is person-centred.  

6.  In  June  2022  Hull  University  Teaching  Hospitals  collaborated  with  the  ICB  and  partners  to 

produce a standardised health passport for people with a learning disability which are brought 

in  by  the  individual  or  carer  and  scanned  into  the  electronic  patient  record  programme, 

Lorenzo, in case of repeat attendances.  

7.  These improvements have been embedded and are in use across adults and children services 

alongside training compliance reviews. 

8.  Fundamental Standards Safeguarding audits have been in place across the organisation since 

2021.  This  audit  reviews  both  service  users  feedback  and  clinicians’  knowledge  of 

safeguarding. Compliance over 2022 and 2023 is seen in the table below.  

Working in partnership: 
Hull University Teaching Hospitals NHS Trust 
Northern Lincolnshire and Goole NHS Foundation Trust 

United by Compassion: 
Driving for Excellence. 

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 8/4/22 

Emergency Care 

X 2 documents – v1.5 

28/4/22 

AMU 

X 1 document – v1.5 

29/9/22 

Emergency Care  

X 1 document – v1.5 

13/10/22 

ED Majors 

X 1 document – v1.5 

8/9/22 

AMU 

X 1 document – v1.5 

28/4/23 

AMU 

X 1 document – v1.6 

19/6/23 

Emergency Care 

X1 document – v1.6 

6/10/23 

Emergency Care 

X1 document – v1 ED specific 

9/10/23 

ED Majors 

X1 document – v1 ED specific 

96% 

91% 

92% 

100% 

91% 

91% 

100% 

99% 

99% 

9.  In  2022,  a  virtual  ward  for  learning  disability  and  safeguarding  was  developed  within  the 

electronic nursing records.  Once a learning disability diagnosis is recorded, an electronic flag 

for learning disabilities remains in place and is pulled through to future episodes of care within 

HUTH.  This  mechanism  allows  the  adult  safeguarding  team  and  learning  disability  liaison 

nurse to identify patients quickly following their admission and then contact the wards (mon-

fri) to provide specialist support and advice on reasonable adjustments and care. 

10. In 2018/19 NHSE/NHSi introduced a national benchmarking exercise to audit the performance 

against  the  learning  disability  improvement  standards  across  NHS  organisations.  These 

improvement standards reflect the strategic objectives and priorities in national publications, 

for example Transforming Care for People with Learning Disabilities and Learning Disability 

Mortality Review (LeDeR).  

11. The Trust has completed this yearly audit and actioned findings.  Learning from best practice 

saw  the  introduction  of the  Northeast  and  Cumbria  Learning  Disabilities  Diamond  Standard 

Acute  Care  Pathway  in  2022/23  in  the  emergency  department,  planned  admissions  and 

outpatient attendances.  

12. The Diamond Standard work supported immediate improvements within the emergency  

Working in partnership: 
Hull University Teaching Hospitals NHS Trust 
Northern Lincolnshire and Goole NHS Foundation Trust 

United by Compassion: 
Driving for Excellence. 

 
 
 
 
 
 
 
 
 
 
 
 
 
 department  by  accommodating  the  individual  with  learning  disabilities  and/or  autism  into 

quieter areas or side rooms and aim to triage, treat and discharge or admit the individual rapidly 

to reduce waiting times and avoid distress.  

13. As a Trust we are now rolling out, as of January 2025 the Oliver McGowan mandatory training 

on Learning Disability and Autism.  The training is named after Oliver McGowan, whose death 

shone a light on the need for health and social care staff to have better training. The Health 

and Care Act 2022 introduced a statutory requirement that regulated service providers must 

ensure their staff receive learning disability and autism training appropriate to their role.  The 

Trust provide the Government's preferred and recommended training for health and social care 

staff.  

14. Oliver's Training also supports the NHS Long Term Workforce Plan ambition by upskilling the 

wider  health  and  care  workforce  to  provide  appropriately  adjusted  care  for  people  with  a 

learning disability and autistic people to reduce health inequality.  The Trusts aim in providing 

the training to all staff is to prevent avoidable deaths like Oliver’s from happening again.  

15. The first phase of the training programme was rolled out to all staff within the ED department.  

The matters of concern raised are addressed as follows: 

A concern that pain is not being accurately assessed in people who are unable to communicate 

using words.  

16. In 2001, Clinical Guideline 171, Guideline for Acute and Peri-Operative Pain Relief in Adult 

Patients provided clinicians with the Abbey Pain Scale and the DisDAT assessment tools for 

use in practice. The Abbey Pain Scale was developed for patients who cannot verbalise pain 

and the DisDAT tool is for patients with learning difficulties to support assessment of distress 

and discomfort.  

Working in partnership: 
Hull University Teaching Hospitals NHS Trust 
Northern Lincolnshire and Goole NHS Foundation Trust 

United by Compassion: 
Driving for Excellence. 

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 17. Compliance with Guideline 171 is completed by way of yearly audits undertaken by the Acute 

Pain Team. 

18. The  Acute  Pain  Team  assess  and  provide  advice  to  Clinicians  and  Nurses  on  referral  in 

relation to effective pain management for patients during their hospital admission across the 

Trust. The team offer effective pain control to both surgical and medical inpatients. 

19. The Acute Pain Team also provide training to doctors, nurses and other health professionals 

in effective pain management. The Clinicians and Nurses have access to online training and 

face to face training is also held at various times though out the year.  Training sessions are 

provided at Induction for Junior Doctors which is mandatory and further mandatory training is 

provided  at  Junior  Doctors  6 month turn round.  The  Junior  Doctors  also  receive  additional 

information  pain  assessment  and  pain  control for their  reference  which they  can take  away 

with them following the training sessions. 

20. The Acute Pain Team also provide specific training to Clinicians twice yearly and training is 

also provided to the ICU department on average twice yearly.  Reference is made to the Abbey 

Pain Scale during all training sessions provided. 

21. In addition to the training highlighted above, face to face bespoke training in pain assessment 

is delivered by the Acute Pain Team when requested by specific hospital departments.  

22. There is an eLearning Pain Assessment module on HUTH’s training platform (HEY247). Up to 

December 2024 317 staff had completed this module, 36 of whom are based in the emergency 

department or acute assessment unit. On the 27 February 2025 it was agreed at the Learning 

and Organisational Steering Group meeting that the eLearning module for pain assessment 

will be mandated across the Trust for all registered Nurses. 

23. Further work to improve the use of the Abbey Pain Scale by clinicians has been undertaken. 

This includes a Standard Operating Procedure, a ‘How to..’ guide and cascade training with 

targeted areas including the Emergency Department Clinical Nurse Educators.   

Working in partnership: 
Hull University Teaching Hospitals NHS Trust 
Northern Lincolnshire and Goole NHS Foundation Trust 

United by Compassion: 
Driving for Excellence. 

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 24. The role of the Clinical Nurse Educators is to provide knowledge and skills to the nursing team 

relevant to the urgent and emergency care service. The team keep abreast of changes in  

practice and responds through policy and guidance updates. They provide induction training 

to new starters and will support members of the team facing additional education needs. 

25. In  addition  to  the  training  provided,  as  outlined  above,  following  the  2022  CQC  inspection 

(published March 2023), the trust acknowledged that pain assessment was not consistently 

assessed for patients who were non-verbal and/or unable to use the visual pain assessment 

scale. In response the Acute Pain Team implemented an action plan to address the issues 

raised which included the following in addition to other action taken. 

•  Laminated posters regarding pain assessment and general management of pain and 

The Abbey Pain Assessment Tool (including QR codes for the SOP, the record chart 

and guide to opioid prescribing) were distributed to every ward and department across 

the Trust to be prominently displayed on the ward.  

•  An email was distributed to the Senior Executive Nursing Team, all Matron's, Band 7 

and 6s across the Trust, instructing that the posters were displayed in staff rooms, work 

stations and anywhere that is visible for the clinical team to access. 

•  The  Trust  created  and  handed  out  credit  card  sized  laminated  guides  which  can  be 

carried in ID badges regarding pain assessment tools and the basic analgesic ladder.  

The  laminated  guides  were  distributed  to  staff  on  the  wards  and  at  the  Link  Nurse 

meeting.  A Link Nurse Meeting is a meeting which is held once per year and the last 

meeting was held in October 2024.  Link Nurse’s have responsibility to upgrade their 

knowledge which is then disseminated to all staff and staff can refer to the Link Nurse 

with their particular questions.  At this meeting work around pain assessment was the 

main focus along with training on the Abbey Pain Assessment tool.    

•  A  blog  was  posted  on  the  Trust  intranet  explaining  pain assessment  scales  and  the 

types of tools which are used in the Trust.  The blog highlights the posters which have 

been distributed and how to use the QR codes to find information regarding the Abbey  

Working in partnership: 
Hull University Teaching Hospitals NHS Trust 
Northern Lincolnshire and Goole NHS Foundation Trust 

United by Compassion: 
Driving for Excellence. 

 
 
 
 
 
 
 
 
 
 
 
 
 
 Pain Assessment Tool. There is also advice about completing the e-learning module 

available on the Trust intranet regarding Pain Assessment. 

26. The Acute Pain Team continue to work with the ICU Department to ensure that appropriate 

assessment  is  conducted  for  all  patients,  including  those  ventilated  or  sedated,  with  the 

possibility of developing a QR code for the on-line Critical Care Pain Observation Tool (CPOT).  

CPOT tool is a tool for assessing pain in ventilated patients and is used in the ICU department 

which staff can access and use when assessing pain. An email was sent in May 2024 to all 

Critical  Care  Staff  to  remind  staff  of  the  CPOT  tool  in  Level  3  care.    In  addition  the  CPOT 

observation tool was laminated and a copy is kept at each bedside for reference with additional 

guidance  for  staff  to  follow.    The  Pain  Link  Team  went  through  the  CPOT  tool  with  each 

member of staff.  In May 2022, the Trust introduced electronic recording as part of its move 

towards  a  paper  light  organisation.  Nervecentre  was  introduced  to  record  clinicians’ 

documentation and assessments. This included the recording of National Early Warning Score 

(NEWS).  Within  the  NEWS  module  was  the  mandatory  recording  of  the  standard  pain 

assessment. This is a verbal response by the patient who describes their experience of pain 

between zero (no pain) and three (severe pain).  

27. In  April  2024,  Hull  University  Teaching  Hospitals  Acute  Pain  Team  completed  an  audit  to 

review progress regarding the assessment of pain. The results produced from the Emergency 

Department audit showed that pain was being assessed in 100% of cases.  However the audit 

demonstrated awareness of the Abbey Pain Assessment tool remained low.  This concern was 

escalated to the Chief Nurse, Corporate Patient Experience Committee.  At the time there was 

no distinction in relation to which pain tool was being used and therefore further action was 

taken in November 2024 as indicated below in terms of changes on Nervecentre.  

28. In response, the Acute Pain Team proceeded to complete two Quality Improvement Projects 

(QIP’s) on awareness and promoting the use of the Abbey Pain Tool. 

a.  QIP  1  –  aimed  at  peri-operative  staff  within  theatres,  anaesthetics  and  the 

critical care service.  

b.  QIP 2 – aimed at medicine and care of the elderly teams 

Working in partnership: 
Hull University Teaching Hospitals NHS Trust 
Northern Lincolnshire and Goole NHS Foundation Trust 

United by Compassion: 
Driving for Excellence. 

 
 
 
 
 
 
 
 
 
 
 
 
 29. Both QIPs included the Acute Pain Team attending induction training for new starters, teaching 

sessions,  poster  campaigns,  drop-in  sessions  and  attendance  at  governance  meetings. 

Results have demonstrated a good increase in awareness across all staffing groups.  

30. In November 2024, a stand-alone pain assessment measure section, not as part of the NEWS 

assessment,  was  introduced  into  Nervecentre  in  response  to  provide  equitable  pain 

assessment for all patients.   Nervecentre was amended to enable clinicians to electronically 

record  pain  assessment  when  using  an  ‘alternative  tool’,  for  example  the  Abbey  Pain 

Assessment  Tool  or  the  Visual  Pain  Assessment  Tool  to  ensure  patients  who  require  a 

reasonable adjustment to accurately assess their pain was accurately recorded. 

31. A  supporting  Standard  Operating  Procedure  was  written  along  with  a  ‘How  to..’  guide  to 

support clinicians using the new standard pain assessment module to ensure clinicians are 

patient-focused  by  using 

the  correct  pain  assessment 

tool 

for 

their  patients 

communication/reasonable adjustment needs.  In relation to the Abbey pain assessment there 

is a link to the presentation online and the documentation is available via the QR code. 

32. Whilst it is too early to tell if this has resulted in a demonstrable improvement of clinician’s pain 

assessments, the Acute Pain and Digital Teams will continue to audit and monitor the progress 

and plan to convert the paper-based Abbey Pain Assessment Tool to an electronic version. 

33. Further audit priorities are to include the quality of assessment and corresponding analgesic 

provision and evaluation. This will be led by the Lead Nurse for Vulnerabilities, supported by 

the Learning Disabilities Liaison Nurse. 

A concern that basic examinations are not being carried out for learning disabled adults at risk of 

pneumonia in the Emergency Department.  

34. The Emergency Department has adopted the Royal College of Emergency Medicine Learning 

Disabilities Toolkit, following the conclusion of the inquest.  

35. Basic examinations, including a chest or respiratory system examination, are routinely carried 

out in the Emergency Department and are part of the routine physical examination of a patient 

that presents with symptoms or signs that require such assessment, including those who are  

Working in partnership: 
Hull University Teaching Hospitals NHS Trust 
Northern Lincolnshire and Goole NHS Foundation Trust 

United by Compassion: 
Driving for Excellence. 

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 at risk of pneumonia.   Appropriate clinical examinations are carried out, as recommended and 

taught  in  clinical  education.  It  is  clinical  judgment  as  to  whether  a  patient  requires  a  chest 

examination or other examination.  

36. Basic examinations are undertaken on all patients and safe methods would be used to ensure 

that it is done effectively and appropriately across all groups of patients.  

37. If  examination  of  the  chest  is  essential  but  not  possible,  the  clinician  would  weigh  the 

risks/benefits of sedating or restraining the patient in order to perform this. This would be if that 

particular examination is essential in the management of the patient. In situations where any 

examination or treatment is essential and the patient is agitated or disturbed, the Royal College 

of  Emergency  Medicine  has  published  the  Best  Practice  Guidance  on  Acute  Behavioural 

Disturbance which provides necessary guidance. This guidance is utilised by clinicians in the 

Emergency Department.  

38. The  Emergency  Department  has  not  identified  any  evidence  to  suggest  that  basic 

examinations  are  not  being  carried  out  specifically  in  patients  with  learning  disabilities. 

Nevertheless the Emergency Department and the Trust continually reflect on how the care and 

treatment can be improved for patients with learning disabilities.  

A concern that NEWS2 scores above 7 are not appropriately escalated.  

39. The Emergency Department follows the CP326: Recognition of the Deteriorating Adult Patient 

Policy.  This  is  a  Trust  wide  policy  and  is  therefore  also  used  outside  of  the  Emergency 

Department.  

40. The  Policy  has  recently  been  reviewed  and  is  in  the  final  stages  of  the  Trust  Governance 

approval processes.  It is expected that the updated policy will be signed off in May 2025.  The 

policy  has  been  updated  to  include  the  Trust  NEWS2  Score  Escalation  Ladder  which 

incorporates an additional step when assessing a patients NEWS2 score. The additional step 

takes  in  to  account  the  family  or  carer’s  views  and  concerns  about  a  patient’s  physical 

wellbeing,  or  any  other  abnormal  parameters  despite  normal  NEWS2  e.g,  reduced  urine 

output, deranged blood results, mottled limbs or just a gut feeling. If there is a concern raised,  

Working in partnership: 
Hull University Teaching Hospitals NHS Trust 
Northern Lincolnshire and Goole NHS Foundation Trust 

United by Compassion: 
Driving for Excellence. 

 
 
 
 
 
 
 
 
 
 
 
 
 
 41. that  would  then  result  in  an  increased  frequency  of  monitoring  and  observations  would  be 

rechecked  after  any  interventions  or  every  15  minutes.    If  the  Clinician  doesn’t  respond  to 

concerns raised staff are directed to contact the Consultant in Charge.  

42. The  updated  policy  provides  clear  guidelines  on  the  escalation  process  in  terms  of  who  to 

escalate to and what the response time should be.  The response times will be in accordance 

with the National Guidelines.  

43. The above policy update is also in line with ‘Martha’s Rule’, which is a major NHS England 

patient safety initiative providing patients and families with a way to seek an urgent review if 

their  own  or  loved  one’s  condition  deteriorates  and  they  are  concerned  this  is  not  being 

responded to.   HUTH are not part of the NHS England Trust Pilot scheme which ends at the 

end of March 2024.  However, the Trust have attended all of the NHS England conferences 

regarding  Martha’s  Rule  and  have  adopted  the  nationally  recognised  patient  wellness 

questionnaire which is being trialled within the Trust and which we  are working hard to embed.   

The Trust have already seen some referral’s under Martha’s Rule to the Critical Care Outreach 

Team  (CCOT).    The  Trust  are committed  to  empowering  patient, families,  carers  and  staff, 

including Nurses and Juniors Doctors to ensure their concerns are listened to and acted upon.  

Martha’s  Rule  is  also  there  to  encourage  and  empower  staff  to  have  the  ability  to  raise 

concerns outside of the official escalation channels. 

44. In  addition  to  and  alongside  the  above  policy  update  a  separate  Trust  Standard  Operating 

Procedure (SOP) to incorporate Martha’s Rule will be introduced.  The wording of the SOP will 

follow NHS England’s recommendations.  It is anticipated that if concerns are raised and no 

action is taken or the action taken is deemed insufficient the patient could be escalated directly 

to the critical care team for assessment.  Under Martha’s Rule the patient or their family will 

not require the treating Doctors opinion to contact the Critical Care Outreach team. 

45. In addition, as is already the case, if a patient’s care has been escalated to the Critical Care 

Outreach Team and then stepped down, due to an improvement in presentation, patients are 

always reminded that if they have any further concerns they can ask the nurse or switchboard 

to bleep the CCOT to re-escalate and they do not have to go through a Clinician to do this. 

Working in partnership: 
Hull University Teaching Hospitals NHS Trust 
Northern Lincolnshire and Goole NHS Foundation Trust 

United by Compassion: 
Driving for Excellence. 

 
 
 
 
 
 
 
 
 
 
 
 
 46. Each time there is an escalation under Martha’s Rule a Trust DATIX will be raised to monitor 

trends,  gather  evidence  of  clinical  incidences  and  highlight  issues  and  concerns  in  Trust 

processes. 

47. Training on the topic of deteriorating patients was provided to all staff until September 2024, 

however, the training had to be stalled due to unforeseen circumstances.  The monthly training 

is due to resume in April 2025 in time for the updated policy roll out.    

48. In addition to the monthly training outlined above the Nurses Training in Simulation and Sepsis 

team  (NUT-S),  have  been  running  training  sessions  since  2022.    The  NUTS-S  team  was 

created off the back of the incident involving Mr Lodge which prompted the development of 

learning and the NUTS-S team have used Mr Lodge’s case as a simulated example within the 

training sessions.  The training was developed by the Trust’s Deputy Director, Hull Institute of 

Learning and Simulation which began as a Pilot training session and was first delivered to the 

Nurses in the Acute Medicine Department and was later rolled out to include the Nursing Team 

within  the  Emergency  Department  and  it  is  now  Trust  wide.    The  training  covers  different 

scenarios, however the structure and focus is always the same and includes a patient who 

shows signs of deterioration.   The focus of the training is to assess, recognise deterioration 

and  escalate  and  there  is  always  a  discussion  around  the  human  factors.    The  training  is 

delivered  by the  Trust  Approved  Nurse  Fellow  in  simulation.    An  example  of the simulation 

training would include a patient with learning difficulties who is unable to express pain, with a 

NEWS2 sore of 7 and who is showing signs of deterioration.  The NUTS-S team continues to 

run weekly training sessions which are Trust wide and can be department focused if there are 

specific issues identified regarding identifying deteriorating patients. 

49. The aim of the Trust team is for the training to become mandatory and discussions are being 

held with the Trust in this regard.  In 2024 the NUTS-S team began work on developing the 

training further with the aim of rolling out the training to multi professionals working in high risk 

areas and dealing with deteriorating patients and a business case has been presented to the 

Board for approval.  The overall aim of the training is to improve patient safety.   

50. A Task and Finish Group has also been set up to make sure education meets the needs of all 

staff groups including medical staff, nursing staff and Health Care Support Workers who come 

into contact with a deteriorating patient and also to cover learning outcomes relating to sepsis. 

Working in partnership: 
Hull University Teaching Hospitals NHS Trust 
Northern Lincolnshire and Goole NHS Foundation Trust 

United by Compassion: 
Driving for Excellence. 

 
 
 
 
 
 
 
 
 
 
 
 51. In  relation  to  Sepsis  the  Trust  has  carried  out  a  substantial  amount  of  work  in  the  Acute 

Assessment Unit and the Emergency Department and data is collected on a daily basis relating 

to  sepsis  screening  and  the  implementation  of  the  correct  management.    Since  the  recent 

changes to NICE guidance the Trust have updated their policy and screening tools and created 

digital versions. 

52. Over  the  last  18-24  months  many  changes  have  been  implemented  in  the  Emergency 

Department for incoming patients who need prompt treatment.  The Emergency Department 

at present have 2 out of 8 bays within the initial assessment area which are earmarked for 

quick assessment and treatment. These are used, when capacity allows, for patients who are 

clinically  unwell  and may  have  a  high  NEWS.  This  allows  for  closer  supervision  and  quick 

assessment of these patients.  

53. The Emergency Department have also introduced an Escalation Clinician and Safety Nurse to 

support the escalation and management of patients that are deteriorating or have deteriorated.  

They  are  designated  on  every  shift  and  their  role  would  include  responding  to  escalation, 

reviewing and treating patients. This is in addition to nursing staff escalating any patient with 

a high NEWS or those they have clinical concerns about. The role of the designated ‘Escalation 

Clinician’ is to respond to any escalating concerns as soon as possible.  

54. The Emergency Department have also introduced a Sepsis Champion on every shift, a role 

performed by an F2 grade clinician, who will ensure that those identified with possible sepsis 

are treated appropriately.   

55. At the streaming desk in the Emergency Department (walk-in area) there is always at least a 

band 6 nurse whose role is to escalate any clinical concerns immediately to the appropriate 

clinician if they identify any patient who is self-presenting and needs urgent review.  

56. Patients with high NEWS in the Emergency Department are initially managed by the clinicians 

in the Emergency Department, with the support of or the direct involvement from registrars or 

consultants. If it is felt that their care would need the expertise and resources beyond the ED, 

the care is then escalated to the speciality teams and/or ICU as clinically required.  

Working in partnership: 
Hull University Teaching Hospitals NHS Trust 
Northern Lincolnshire and Goole NHS Foundation Trust 

United by Compassion: 
Driving for Excellence. 

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 57. In addition we have seen the introduction of the High Observation Bay (HOB) in AMU which is 

for higher acuity patients who are placed in the bay with a higher nursing ratio. 

52. The Emergency Department continue to be under significant pressures due to capacity. All the 

above  measures  are  in place  to  minimise  the  risk  of  NEWS  scores  not  being  appropriately 

escalated. The Trust will continue to monitor the effectiveness of the measures that have been 

implemented.  

A concern that opportunities for learning from serious incidents are being lost.  

53. Information  of  Davids  death  was  provided  by  the  emergency  department  to  the  Mental 

Capacity Act lead. No concerns were raised regarding omissions in care or treatment during 

the hours spent at Hull University Teaching Hospitals. A safeguarding concern was submitted 

to  the  relevant  Local  Authority  for  investigation  due  to  the  pathway  of  admission  and  prior 

knowledge of community safeguarding issues.  Mr Lodge’s death was also reported to LeDeR 

who confirmed that a review of care would be completed at the conclusion of the inquest. 

54. Serious Incidents are declared following a patient safety event whereby the severity of harm 

caused is determined to be moderate or higher. Harm was not deemed to have been caused 

by Hull University Teaching Hospitals therefore a serious incident was not declared. 

55. However,  since  Mr  Lodge’s  death,  Trust  process  and  procedure  has  developed  and  going 

forward  a  Structured  Judgement  Review  (SJR)  is  completed  for  all  patient’s  with  identified 

learning disabilities and who sadly pass away while receiving care and treatment at the Trust.  

The  SJR  will  be  completed  by  the  Vulnerabilities  and  Enhanced  Care.    The  SJR  will  be 

completed despite the outcome of the initial clinical review of the care and treatment provided 

and despite the outcome of the decision from LeDeR in terms of their investigation.   

56. The  Trust  hold  Weekly  Patient  Safety  Summit  (WPSS)  meetings  to  discuss  patient  safety 

concerns.  Senior Clinical and Nursing staff as well as Clinical and Governance Leads from 

the Care Groups all attend this meeting. 

57. Service condition 26 of the NHS Standard Contract requires any provider of services to the 

NHS to participate in the projects within the National Clinical Audit and Patient Outcomes  

Working in partnership: 
Hull University Teaching Hospitals NHS Trust 
Northern Lincolnshire and Goole NHS Foundation Trust 

United by Compassion: 
Driving for Excellence. 

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 58. Programme relevant to the Services. This includes the Learning Disabilities Mortality Review 

programme (LeDeR) of which NHS Humber Health Partnership is a member of the Humber 

Steering Group.  Mr Lodge’s case was referred to LeDeR prior to the inquest and action was  

to be considered following the conclusion of the inquest.  The Trust are aware that the LeDeR 

Panel  Review  Group  are  carrying  out  of  full  review  of  the  care  and  treatment  Mr  Lodge 

received.  The Panel Review Group meet every two weeks and the action plan ensuing from 

the review, which relates to the Trust will be monitored at the Panel Review meetings.  The 

action plan across the ICB would be managed by the Humber Steering Group. 

59. The Humber LeDeR Steering Group have developed learning briefings with good practice and 

areas for improvement presented from reviews that have occurred across the Humber region 

in both primary and secondary care. These briefings are shared at the internal Mental Health, 

Learning Disability & Autism Steering Group, internal End of Life Steering Group and with the 

Trusts  mortality  team  manager.  In  addition,  the  briefings  are  made  available  on  the  Trust 

Learning Disabilities intranet website for staff to access. 

60. Learning from the Humber LeDeR briefings that are directly related to the Trust are discussed, 

with subsequent improvement actions and implementation plans agreed and monitored at the 

Mental Health, Learning Disability & Autism Steering Group.   

. 

We trust this responds to the matters raised within the prevention of future deaths report. 

Yours faithfully 

Group Chief Nurse 

Working in partnership: 
Hull University Teaching Hospitals NHS Trust 
Northern Lincolnshire and Goole NHS Foundation Trust 

United by Compassion: 
Driving for Excellence.

Mr Edward Steele  
HM Assistant Coroner  
East Riding and Hull Coroner’s Service 
The Guildhall 
Aldred Gelder Street  
Hull  
HU1 2AA  

National Medical Director  
NHS England  
Wellington House 
133-155 Waterloo Road  
London 
SE1 8UG 

17 March 2025 

Dear Coroner, 

Re: Regulation 28 Report to Prevent Future Deaths – David Christopher Peter 
Lodge who died on 13 January 2022 

Thank  you  for  your  Report  to  Prevent  Future  Deaths  (hereafter  “Report”)  dated  23 
December  2024  concerning  the  death  of  David  Christopher  Peter  Lodge  on  13 
January 2022. In advance of responding to the specific concerns raised in your Report, 
I would like to express my deep condolences to David’s family and loved ones. NHS 
England are keen to assure the family and the Coroner that the concerns raised about 
David’s care have been listened to and reflected upon.   

I am grateful for the further time granted to respond to your Report, and I apologise for 
any  anguish  this  delay  may  have  caused  David’s  family  or  friends.  I  realise  that 
responses to Coroners’ Reports can form part of the important process of family and 
friends coming to terms with what has happened to their loved ones, and I appreciate 
this will have been an incredibly difficult time for them. 

Your  Report  raised  concerns  that  no  reasonable  adjustments  were  made  at  the 
Emergency Department (ED) David was being treated at to assess David’s pain, given 
that he was not able to communicate verbally with medical professionals, that basic 
examinations  were  not  carried  out,  and  that  NEWS2  scores  above  seven  were  not 
being appropriately escalated.  

In response to the specific questions of the Coroner, NHS England was not involved 
directly in providing clinical care to David and therefore does not have access to the 
clinical records of the Trust where he was admitted. On account of this, NHS England 
cannot  comment directly  on  the  care  he  received.  I note  that  your  Report  was also 
sent  to  Hull  University  Teaching  Hospitals  NHS  Trust,  and  it  appropriate  that  they 
respond to the Coroner’s concerns specifically relating to David’s care and treatment. 
Humber  and  North  Yorkshire  Integrated  Care  Board  (ICB),  the  responsible 
commissioner for the Trust, is engaging with the Trust on their response and will share 

                                                                                                                       
 
 
 
 
 
 
 
  
 
 
 
 
  
 this with regional colleagues in due course. We are advised that the LeDeR review1 
for David’s case is ongoing, with the panel scheduled for 20th March 2025.  

Reasonable  adjustments  and  basic  examinations  for  people  with  learning 
disabilities 

The  issues  raised  about  David’s  care  include  diagnostic  overshadowing,  where the 
agitation  would  appear  to  have  been  attributed  to  his  learning  disability,  for  which 
reason sedative medication was administered, whereas the agitation may have been 
due to a physical cause such as pain or shortness of breath. 

To ensure that learnings are taken, NHS England can disseminate the findings from 
the case of David through our network of contacts in health services. NHS England 
can inform the Medical Royal Colleges and the professional bodies for doctors of the 
lessons to be learned from the case, for dissemination to their members. The relevant 
professional bodies include the Royal College of Physicians (London), Royal College 
of Emergency Medicine, and Royal College of General Practitioners.  

Staff training on the presentation of illness in people with learning disability is important 
in  ensuring  that  illness  is  detected  through  careful  clinical  practice,  which  should 
involve reasonable adjustments during the assessment process to elicit the relevant 
clinical signs. The Health and Care Act 2022 introduced a statutory requirement that 
regulated  service  providers  must  ensure  their  staff  receive  learning  disability  and 
autism training appropriate to their role. The Oliver McGowan Mandatory Training is 
the standardised training that was developed for this purpose, and is the government’s 
preferred  and  recommended  training  for  health  and  social  care  staff.  All  healthcare 
professionals are required to undertake some of the e-learning, regardless of where 
they work within the health system.    

David was a vulnerable adult who was dependent on an elderly parent, with no other 
apparent social support. The welfare of vulnerable adults is largely the responsibility 
of  local authorities  and  other  community agencies,  yet  David and  his  father  did  not 
have contact with social care services for four days or more. A proactive system of 
support to David and his father could have alerted services to the perilous state that 
they were in. NHS England can emphasise to member agencies of Integrated Care 
Partnerships their important role in supporting and safeguarding vulnerable families.   

NEWS2 Scores  

NEWS2 is the latest version of the National Early Warning System, first produced in 
2012 and updated in December 2017, which advocates a system to standardise the 
assessment and response to acute illness. 

1 LeDeR reviews are undertaken to review the health and social care received by people with a 
learning disability and autistic people (aged four years and over) who have died, using a standardised 
review process. They are undertaken by Integrated Care Systems.  

 
 
 
 
 
 
 
 
 NEWS is based on a simple aggregate scoring system in which a score is allocated to 
physiological  measurements,  already  recorded  in  routine  practice,  when  patients 
present  to,  or  are  being  monitored  in  hospital.  An  aggregated  score  of  above  7  is 
considered high clinical risk and should trigger an urgent or emergency response by 
a  clinician  or  team  with  competence  in  the  assessment  and  treatment  of  acutely  ill 
patients, including recognising when the escalation of care to a critical care team is 
appropriate.  The  response  team  must  also  include  staff  with  critical  care  skills, 
including airway management. 

In this case, where a NEWS score of 8 or 9 was recorded consistently for a number of 
hours, the appropriate response does not seem to have been taken.  

In  January  2019,  NHS  England,  in  partnership  with  NHS  Improvement,  Health 
Education  England  and  the  Royal  College  of  Physicians,  published  the  NEWS2 
resource pack. Developed with clinical input, the pack provides access to tools and 
resources  which  support  planning  and  delivery  of  NEWS2  implementation  and 
illustrates practical examples of how it is being implemented across the country. 

Learning from serious incidents  

Your  Report  also  raised  the  concern  that  no  internal  investigation  or  other  form  of 
serious incident investigation was undertaken.  

As  referenced  above,  NHS  England  has  a  significant  learning  disability  mortality 
review (LeDeR) programme which outlines a clear expectation that “Integrated Care 
Systems (ICSs) will be responsible for ensuring that LeDeR reviews are completed of 
the  health  and  social care  received  by  people  with  a  learning  disability  and  autistic 
people  (aged  four  years  and  over)  who  have  died,  using  the  standardised  review 
process”.  A  LeDeR  review  is  currently  in  progress  to  look  at  the  care  delivered  to 
David.  

In  addition,  NHS  England’s  Patient  Safety  Incident  Response  Framework  (PSIRF) 
guidance ‘Guide to responding proportionately to patient safety incidents’ clearly sets 
out in Appendix A the ‘events requiring a specific type of response as set out in policies 
and regulations’. For deaths of persons with learning disabilities, trusts should ‘refer 
for Learning Disability Mortality Review (LeDeR)’ and the guidance notes that ‘Locally 
led  PSII  [patient  safety  incident  investigation]  (or  other  response)  may  be  required 
alongside the LeDeR’. 

I  would  also  like  to  provide  further  assurances  on  the  national  NHS  England  work 
taking  place around  the  Reports  to  Prevent Future  Deaths.  All  reports  received  are 
discussed  by  the  Regulation  28  Working  Group,  comprising  Regional  Medical 
Directors,  and  other  clinical  and  quality  colleagues  from  across  the  regions.  This 
ensures that key learnings and insights around events, such as the sad death of David, 
are shared across the NHS at both a national and regional level and helps us to pay 
close attention to any emerging trends that may require further review and action.   

Thank you for bringing these important patient safety issues to my attention and please 
do not hesitate to contact me should you need any further information.  

 
 
 
 Yours sincerely,  

National Medical Director