Sumber kasus: metro.co.

uk, 29 September 2019

A man with Down’s syndrome died of neglect after not being fed for 19
days in hospital, an inquest has found.

The family of Giuseppe Ulleri, known as Joe, spoke of their devastation after the five-
day hearing, which concluded there had been failures in his care, and they contributed to
his death.
The Ulleri family say their beloved Joe, 61, died ‘in the most horrendous way’. To add
to their misery, Joe’s father passed away just weeks ago without getting closure.
An inquest jury found Joe passed away following ‘a failure in his overall care’ while
being looked after at the Manchester Royal Infirmary (MRI) in 2016.
Staff wrongly nursed him in a lying down position and failed to provide him with
adequate nutrition, the court heard.
‘This constituted neglect,’ a jury foreman told the hearing at Manchester Coroners’
Court on Friday.
Bosses at MRI said the care Joe received ‘fell well below [its] standards’, and said they
have implemented new measures in light of his tragic death.
Joe’s brothers Giovanni and Peter said they hoped Joe’s case will be a catalyst for
change in the way people with learning disabilities are cared for in hThe inquest earlier
heard Joe was non-verbal and had Down’s syndrome and learning difficulties.
He was born in Bolton, but raised in south Manchester with his ‘fiery and loving’ Italian
family.
He lived happily in an assisted care facility, L’Arche in Withington, but a fall in the
night in February 2016 sparked a catalogue of events that ended in his death on March
25, 2016.
Joe was admitted to hospital in the February after care staff discovered he had fallen, the
inquest heard.
Doctors didn’t realise the extent of his injuries and discharged him, despite the fact he
had fractured his wrist and hip, and a had broken vertebrae in his neck.
Concerned staff at L’Arche took Joe back to the hospital the following day and he was
re-admitted.
He remained there until he died of aspiration pneumonia – a condition where bits of
food or saliva are inhaled into the lungs and cause infection.
The court heard Joe suffered dramatic weight loss after not being fed for 19 days in
hospital.
At the start of his admission, he weighed 56kg. By the time he died, he was just 44kg.
The lack of nutrition increased his risk of infection, the court heard. Joe was not
provided with adequate pain medication at MRI, the inquest heard.
Joe was nursed lying down most of the time due to a miscommunication on his medical
records, the inquest was told.
The court heard that may have affected his breathing and led to aspiration pneumonia.
An independent expert told the court Joe could have lived longer had hospital staff
reviewed his antibiotics and put him on stronger medication to cure the pneumonia.
The inquest heard an email was sent by Chris Hazelhurst, a social worker, to Sheila
Mooney, who was responsible for safeguarding at the hospital.
Mr Hazlehurst raised concerns about the standard of Joe’s care, including nutrition and
pain relief.
Yet those concerns were never communicated to the surgeon overseeing his care, Sanat
Shah, the court was told.
The jury, returning a narrative verdict on Friday (March 29), said Joe received
‘inadequate nutrition plus delays to procedures’ to resolve his condition.
‘Despite the fact that fractures were treated appropriately, there no consideration of the
balance of the short term risk of aspiration against the long term risk of the hip fracture
not healing correctly,’ the jury foreman said.
Delivering a narrative conclusion, the foreman said: ‘Giuseppe Ulleri was admitted to
hospital following a fall.
‘During his stay there, a failure in his overall care, specifically nursing him in a supine
position and a failure to provide adequate nutrition.
‘This constituted neglect. Giuseppe Ulleri contracted aspiration pneumonia and passed
away on March 20, 2016.
‘The failures in care contributed to Giuseppe Ulleri’s death.’
The medical cause of the death was recorded as aspiration pneumonia and pulmonary
embolism.
During the inquest, Joe’s devastated brothers Giovanni and Peter Ulleri described him
as a ‘gift from God’.
Giovanni said their father Pietro died three weeks ago without knowing the full details
of what happened to his son.
Joe’s brother Giovanni, reading a statement on behalf of the Ulleri family, said: ‘Our
brother was the kindest and gentlest soul, yet he was allowed to die in the most
horrendous way.
‘Not only was he thoroughly neglected, he was starved for 19 days in hospital and
denied proper pain management.
‘Joe’s entirely preventable and premature death came as a result of the catastrophic
failures from the Manchester Royal Infirmary, who were supposed to be caring for
him.’
Giovanni, who broke down in tears after the inquest concluded, added: ‘Joe’s case
needs to be a catalyst for change.
‘There are too many Joes, although often, their premature deaths remain unreported and
uninvestigated.
‘All too often people with learning disabilities are treated as second class citizens by the
NHS and end up dying from indifference.
‘The NHS and society as a whole needs to learn from Joe’s death to ensure nobody else
with learning disability suffers in the same way that he did.
‘If we get health care right for people with learning disabilities, then we are likely to
improve it for everyone.’
Professor Jane Eddleston, joint group medical director at Manchester University NHS
Foundation Trust, which runs MRI, said: ‘We wish to again offer our condolences and
deepest sympathies to Joe’s family.
‘The trust accepts fully the conclusion and findings of the Coroner following the
outcome of [the] inquest.
‘The care provided to Joe fell well below our standards and for this we apologise
sincerely.
‘Following Joe’s sad death, we immediately launched an investigation to examine the
care he received and since then, we have implemented a number of measures to ensure
that this does not happen again.
‘Through the implementation of a detailed action plan, we have strengthened consultant
leadership and continuity of care on the unit; undertaken extensive work on nutrition
and hydration; and focused on how we care for our patients who have a learning
disability.
‘This work has included improvements to strengthen our processes for monitoring and
supporting nutrition and hydration for patients and establishing pathways for patients
with complex nutritional needs, so their individual needs are regularly reviewed and that
their specific requirements are identified and addressed.
‘Nutrition specialist nurses continue to provide bespoke training for staff and our work
to continuously improve our patients’ experience in this area is ongoing.
‘In view of the inquest findings, the trust will re-examine its investigation and would
like to extend an invitation to Joe’s family to discuss this further to ensure that all issues
are considered fully and all improvements implemented.
‘We are committed to ensuring that lessons are learned to improve patient care.’