Emergency care assistants did not follow correct procedures when taking a man to his hospital appointment, an inquest has heard.

David Butler, of Mill Road in Emneth, died aged 48 at Lynn’s Queen Elizabeth Hospital on April 5, 2024.

An inquest, which began on Tuesday at Norfolk Coroners’ Court in Norwich, has been investigating the circumstances leading to his death, and over the last few days it has established that he was left paralysed from the waist down following a fall.

It was also said that Mr Butler was suffering from a severe sore on his buttocks, which at times had turned black and necrotic.

Today, emergency care assistant Simon Frost, of Health Transportation Group (formerly ERS medical transport), gave evidence at the hearing and admitted he was ordered to transport Mr Butler to a doctor’s appointment at the QEH without any knowledge of his complex needs.

During transportation, Mr Butler’s wheelchair suffered a fault, meaning he had to be transferred onto a new one upon his arrival at the hospital.

Mr Butler’s family has thrown into question whether enough care was given to his sore when transporting him between chairs.

The inquest heard there were policies in place stating that for transporting patients in Mr Butler’s obese condition, 24-hour notice is supposed to be given to allow a risk assessment to take place.

However, Mr Frost was not aware of this being done and admitted he was only told about going to pick up Mr Butler on the day.

“We weren’t told of any risk assessments. We’re given the patients we’re given, and that continues to this day,” he said.

“We don’t have any formal documentation when it comes through, and in terms of the patient, that’s the team leaders and managers who should be assessing that.”

Representing Mr Butler’s family, barrister Mike Sheehan said he was “a little surprised” to hear that during his career, Mr Frost had never seen an assessment prior to picking up a patient, as the policy stated.

Mr Sheehan said that had the risk assessments been completed, the transportation team would have been aware of the sore.

During his statement, Mr Frost said no complaints of discomfort were made by Mr Butler.

However, Mr Sheehan said that Mr Frost would not have known if Mr Butler was feeling discomfort in his sore, given that he was paralysed from the waist down.

“I didn’t realise he had no feelings in terms of that – but that’s naivety. We ask every patient if they are they comfortable because we can’t examine patients.”

Mr Butler’s preliminary cause of death was previously listed as multi-organ failure as a result of a sore on his back from a spinal cord injury.

Other contributing factors included alcohol-related liver disease, obesity and diabetes.

The inquest was supposed to conclude this afternoon, but has overrun. It is set to continue on another date, yet been confirmed.