Coroner holds Royal Berkshire Hospital failings contributed to sepsis death
Following a 3-day inquest, the coroner found errors on the part of clinicians and systemic failings at the Royal Berkshire Hospital contributed to the death of 48-year-old father of one, Michael Nye. Michael died from a Strep A infection and sepsis.
Previously fit and healthy, Michael attended the Royal Berkshire Hospital with a 48-hour history of flu like symptoms, sore throat, arm pain and a rash. While recognising Michael looked seriously unwell and having information from a blood gas indicating a significantly raised lactate, the Emergency Department consultant did not think infection and sepsis, choosing instead to attribute Michael's condition to a rare limb threatening condition involving a blood clot in the upper arm.
This led to Michael not receiving crucial and potentially life-saving antibiotics for more than five hours. Every hour that sepsis is untreated increases the risk of dying. The coroner heard evidence that had Michael been treated by the ED Consultant at the initial review, he had a less than 50% probability of dying.
The coroner was concerned that other people are at risk of death by the failings at RBH and will be issuing a number of Prevention of Future Death Reports to the Trust.
Deborah Nadel who represented the family said, "We recognise the intense pressures doctors are under but this case highlights there is still vital work to be done to get our doctors to think sepsis and react rapidly.
Despite ongoing campaigns to raise awareness instigated by the NHS and the Sepsis Trust, we hear too many cases of people losing a family member in hospital from a failure to recognise or treat infection and sepsis quickly enough."
Michael's partner said:
'No one should go to hospital on an autumn evening with a treatable infection and not come home.
'Our darling Michael was failed minute by minute. Sepsis doesn’t respect time, it ravages and kills loved ones. Our doctors seem to remain incapable of recognising and treating sepsis with the urgency it demands.
'My focus at this inquest was to convert yet another NHS statistic back into the person we knew and loved – a son, brother, partner and daddy. Michael died 2 weeks and 4 days before our beautiful son’s 4TH birthday. I will forever be so, so, sad that Michael was denied the chance to continue this great adventure called ‘life’ with us. '
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