'My brother was allowed to die in the most horrendous way' - inquest found failures in care led to death of man with Down's Syndrome

The inquest into the death of a Withington man with Down's Sydrome, who died in hospital after going nearly 19 days without food, has concluded.

The jury heard three days of evidence from Joe Ulleri's family, carers and medical staff at Manchester Royal Infirmary and reached concluded he died of pneumonia and a pulmonary embolism, but that failures in care at Manchester Royal Infirmary contributed to his death.

Joe, who lived in supported accommodation in Withington, was admitted to hospital on February 26th 2016 after a fall.

The court heard what followed was a 'catalogue of failings', including poor nutrition, lack of pain relief and miscommunication.

Joe was initially checked for an ankle injury but, after doctors examined him, they concluded it was not serious and discharged him.

But he was sent back to hospital the next day and found to have actually broken his hip, neck and right wrist.

Once he was admitted, he ended up going a total of 19 days without adequate nutrition.

As part of their conclusion, the jury said there was a 'lack of a joined up approach in Joe's care, lack of senior input, and inadequate use of appropriate documentation.'

They wrote all that led to 'unsatisfactory care for Joe' and an 'inadequate consideration of Joe's additional needs.'

Giovanni Ulleri, Joe's younger brother, said:

“My 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 10 days in hospital. This inexplicable and avoidable tragedy came as a result of the catastrophic failures from those supposed to be caring for him.

“I was worried Joe was being forgotten about, a belief that turned out to be true. Joe couldn’t talk for himself and now I feel so angry and incredibly guilty about his death. If I had only known what was going on I would have challenged everything the doctors said and did.

“Joe’s case needs to be a catalyst for change. 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 my brother’s death to ensure nobody else with learning disability suffers in the same way that he did.”

Nina Ali, a Partner from Hodge Jones & Allen, who represents the family, said: “This is one of the most horrific, tragic and yet avoidable cases I have ever dealt with. Joe was a healthy man. With the right care and treatment Joe’s broken bones would have healed. He may well have recovered and gone home. The way in which he was neglected, left to deteriorate and not given any food for 10 days is indefensible."

Professor Jane Eddleston, Joint Group Medical Director at Manchester University NHS Foundation Trust, that runs Manchester Royal Infirmary, 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 today’s 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.

“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.”