The man with Down syndrome n was not fed for 19 days & # 39; before dying at the hospital

A jury of inquiry concluded that Joe died after "a failure in his care" when he was treated at the Manchester Royal Infirmary (MRI) in 2016.

The staff fed him poorly while lying down and failed to provide him with adequate food, the court said.

"This is negligence," said a jury chairman on Friday at the Manchester Coroners Court hearing.

MRI bosses said that Joe's care "is well below that of [its] standards "and stated that they have implemented new measures in the light of his tragic death.

Joe's brothers, Giovanni and Peter, expressed hope that Joe's case would be a catalyst for change in the way people with learning disabilities are treated at the hospital.

The investigation revealed that Joe was non-verbal and was suffering from Down syndrome and learning disabilities.

He was born in Bolton, but grew up in the south of Manchester with his "ardent and loving" Italian family.

He lived happily in a care facility, L'Arche in Withington, but a fall in the night of February 2016 unleashed a series of events that culminated in his death on March 25, 2016.

Joe was admitted to the hospital in February after the caregiver had discovered that he had fallen, announced the judicial investigation.

The doctors did not realize the extent of his injuries and released him despite the fact that he had fractured his wrist and hip and a vertebra had fractured his neck.

Concerned L'Arche staff brought Joe back to the hospital the next day and he was readmitted.

He remained there until his death from aspiration pneumonia, a disease in which pieces of food or saliva are inhaled into the lungs and cause an infection.

The court heard that Joe had suffered a dramatic weight loss after not being fed for 19 days at the hospital.

At the beginning of his admission, he weighed 56 kg. When he died, he weighed just 44 kg.

Lack of nutrition increased the risk of infection, the court said. The investigation revealed that Joe was not receiving adequate badgesia at the MRI.

He started taking paracetamol to treat his injuries. A doctor told a support worker that a "normal person" would have received a complete femoral block for pain.

The investigation revealed that Joe had been treated most of the time lying because of poor communication in his medical record.

The court was told that his breathing could be affected and that he had caused aspiration pneumonia.

An independent expert told the court that Joe could have lived longer if hospital staff had examined his antibiotics and had prescribed more effective medications to treat pneumonia.

The investigation revealed that Chris Hazelhurst, social worker, had sent an email to Sheila Mooney, head of protection at the hospital.

Hazlehurst raised concerns about Joe's level of care, including nutrition and pain relief.

Yet, these concerns were never communicated to the surgeon responsible for his care, Sanat Shah, was informed of the court.

The jury, which issued a narrative verdict Friday (March 29), said Joe had received "inadequate nutrition with delays in the proceedings" to solve his problem.

"Despite the fact that fractures have been treated appropriately, the risk of short-term aspiration and the long-term risk that the hip fracture will not heal properly are not taken into account," he said. the president of the jury.

Presenting a narrative conclusion, the foreman stated: "Giuseppe Ulleri was admitted to the hospital following a fall.

"During his stay there, he was not treated as a whole, especially badfeeding while lying down and had not fed enough.

"This was negligence. Giuseppe Ulleri contracted aspiration pneumonia and died on March 20, 2016.

"The failures in the care contributed to the death of Giuseppe Ulleri."

The medical cause of death was aspiration pneumonia and pulmonary embolism.

During the investigation, Joe's devastated brothers, Giovanni and Peter Ulleri, described it as a "gift from God."

Giovanni said that their father, Pietro, died three weeks ago without knowing all the 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 sweetest soul, but he was allowed to die in the most horrible way possible. .

"Not only was he completely neglected, he was deprived of food for 19 days at the hospital and was denied treatment for the pain.

"Joe's preventable and untimely death is the result of the catastrophic failures of the Manchester Royal Infirmary, who were supposed to look after him."

Giovanni, who burst into tears after the close of the investigation, added, "Joe's case has to be a catalyst for change.

"There are too many girls, even though their premature deaths are often not reported or reviewed.

"Too often, people with learning disabilities are treated by the NHS as second-clbad citizens and end up dying of indifference.

"The NHS and society as a whole must learn from Joe's death to make sure no one with a learning disability suffers in the same way as him.

"If health care is suitable for people with learning disabilities, it is likely that we will improve it for everyone."

Professor Jane Eddleston, the group's medical director with the NHS Foundation Trust at the University of Manchester, who manages MRI, said: "Once again, we would like to extend our condolences and our deepest condolences to Joe's family.

"The trust fully accepts the findings and conclusions of the coroner following the result of [the] investigation.

"The care of Joe is well below our standards and we sincerely apologize.

"After Joe's tragic death, we immediately launched an investigation to examine the care he had received. Since then, we have put in place a number of measures to prevent this from happening again.

"Through the implementation of a comprehensive action plan, we have strengthened consultant leadership and continuity of care in the unit; undertook extensive work on nutrition and hydration; and focused on how we care for our patients who have an intellectual disability.

"This work included improvements to strengthen our processes for monitoring and managing patient nutrition and hydration, and establishing pathways for patients with complex nutritional needs. Thus, their individual needs are regularly reviewed and their specific needs identified and addressed.

"Nutrition nurses continue to train our staff and our work to continually improve the patient experience in this area is ongoing.

"Based on the findings of the investigation, the trust will reconsider its investigation and would like to invite Joe's family to further discuss it to ensure that all issues are addressed and that any improvements made are implemented.

"We are committed to ensuring that lessons are learned to improve patient care."