It is not possible to say whether a fit and healthy student who died in hospital with sepsis would have survived if he had been treated earlier, a coroner has ruled.
William Hewes, 22, of Islington, north London, died at Homerton University Hospital (HUH) on January 21 2023 within 24 hours of being admitted after his meningitis, caused by a meningococcal infection, developed into sepsis.
The 6ft 6ins history and politics student was rushed to the emergency department by his mother, consultant paediatrician Deborah Burns, who was a doctor at that same east London hospital for more than 20 years.
An inquest in February at Bow Coroner’s Court heard medical staff failed to administer antibiotics swiftly to Mr Hewes and Dr Burns said her son was “left unmonitored and untreated in resus for far too long”, and that his care “was no better on the ICU until it was too late”.
In a narrative conclusion delivered on Thursday, senior coroner Mary Hassell said he did not get treatment including antibiotics and fluids “with the urgency that he should have”. She gave the medical cause of death as meningococcal septicaemia.
The coroner also said “he was already very unwell when he arrived and it is unclear whether if he had been administered all appropriate treatment promptly, his life would have been saved”.
In a statement on Thursday, Dr Burns said: “I hope that the outcome of the coroner’s inquest can lead to learning and improvement to the care of people with sepsis in the future.”
She added: “On the night I took William to hospital I knew he needed antibiotics as soon as possible but I witnessed a delay.
“In all, I raised the alarm eight times. On one occasion I was told the antibiotics had been given when they had not.”
She added: “My pursuit of the truth is not about blame. It has always been driven by concerns about the standard of care I witnessed in my own emergency department.”
The coroner said “the real area of contention” is whether earlier treatment would have changed the outcome.
The inquest heard expert witnesses gave differing opinions, backed by data, relating to Mr Hewes’ chances of survival if he had been treated earlier.
The coroner explained: “I have thought carefully about each opinion, which I find were honestly and at times passionately given, but ultimately I am not persuaded by either. What I conclude is not that I cannot choose between them. It is that I choose neither.
“I am not convinced, even on the balance of probabilities, that the state of medical knowledge is such that we know the answer to the question of whether William would have survived had he received earlier treatment when he got to hospital.”
Mr Hewes became unwell at approximately 1.30pm on January 20 and said he felt cold and had a headache.
He felt worse during the day and got up after going to bed that night to tell his mother that he now felt very unwell and had bruising on his belly.
His mother suspected meningococcal sepsis, rang the hospital emergency department and warned them she and her son were on their way.
She described her son’s signs and symptoms, and he was then “medically assessed promptly”, the coroner said.
She added: “By the time of his assessment in hospital, William had an almost 11-hour history of being unwell.”
He was still alert and speaking but presented with a range of issues, including active vomiting, severe headache and intense pain in his right flank.
All the medical and nursing staff who cared for him “immediately recognised” that he was “a patient with life-threatening sepsis”, the coroner said.
The decision to transfer to ITU was made at 3.09am and Mr Hewes arrived there at 4am.
The coroner noted that “the national standard of a maximum of four hours to transfer in such a situation was not breached”, but added “with hindsight, by then, his condition was probably irretrievable”.
Dr Ron Daniels, UK Sepsis Trust founder and chief executive, had told the inquest Mr Hewes was likely to have survived if he had received prompt care, and said it is “perfectly possible” for non-specialist medical staff to deliver the necessary treatment.
Former NHS consultant in intensive care Professor Patrick Nee, who said he was instructed by the hospital trust to assist with their review, told the court it would be “a leap” to say Mr Hewes would have survived if his hospital care had been different.
The coroner said she will be issuing a prevention of future deaths report as improvements which have been made since Mr Hewes’ death “should be shared”.
She said: “I find it difficult to believe if this happened in the Homerton, it could not happen elsewhere.”
After the hearing Dr Daniels said there were “significant delays in William’s treatment, including the failure to administer basics like antibiotics and fluids, and as a result William was not given the opportunity to survive”.
Deborah Nadel, of Fieldfisher law firm representing the family, said: “The family are devastated to have lost William in these circumstances.
“Unless errors like those identified during the inquest are discussed and acknowledged, lessons are not learned and nothing changes.”
She said: “We will continue to investigate whether the errors clearly identified during the inquest did cause or make a material contribution to William’s death.”
A Homerton Healthcare NHS Foundation Trust spokesman said: “William’s case was thoroughly reviewed by our team and by independent experts.
“They found there were aspects of his care that could have been done differently, from which we have learned and made changes and improvements.
“A full action plan was drawn up following the investigation into William’s death and several improvements have been made relating to how clinical staff manage suspected sepsis cases in our emergency department.”
He described Mr Hewes’ death as “devastating to his family and deeply touched everyone involved in his care”.
He also passed on condolences to the Hewes family, including Dr Burns who is “a much admired and respected consultant paediatrician in our team at Homerton”.
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