Sepsis death of Leeds student was not primarily caused by antibiotics error, inquest hears

An inquest has heard a Leeds student, who died from sepsis following a miscommunication related to his antibiotics administration, would probably not have survived even if his care had been different.

In January 2023, 22-year-old William Hewes died at Homerton University Hospital in east London, after his meningitis developed into sepsis.

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Ms Hassall said Martha Mills’ parents, whose daughter died from sepsis two years ago, sat before her “in a very similar situation”. As a result their campaigning, patients and their loved ones have the right to a second medical opinion, which is being introduced nationally.

She added: “It seems to me that improvements can be made up and down the country as a result of William’s death.”

The inquest had previously heard the hospital did not adhere to national guidelines when it failed to administer antibiotics within an hour of Mr Hewes’ arrival, who was studying history and politics at the University of Leeds at the time of his death. 

Dr Petr Dlouhy, the ICU consultant on call that night, believed Mr Hewes should have been admitted to the ICU because he was on the verge of multiple organ failure. 

The ICU registrar, Dr Mathuratha Sivasubramaniam, reviewed his condition at around 1.09am and did not believe the former student needed an ICU admission.

In a statement read out by the coroner, she said she believed he was responding to treatment and his early warning signs were improving.

Several phone calls were made by Dr Lake to the ICU registrar asking to move Mr Hewes to intensive care at around 1.50am and 2am. 

Dr McMillan said she felt as though her call was not treated with the appropriate urgency, as the ICU registrar had not come back to check on Mr Hewes.

This then prompted senior charge nurse Luke Brown to make another phone call. But, by this point, Mr Hewes’ condition had deteriorated.

He was dependent on oxygen support, his vision was rapidly declining, and his urine output was so low Dr McMillan suspected his kidneys were failing.

Dr Dloughy admitted Dr Sivasubramaniam should have called him earlier than 3am, when she asked if Mr Hewes should be admitted to intensive care.

He claimed that if he had known about Mr Hewes’ worsening condition, he would have “obviously” moved him to intensive care before 3am. 

Dr Dloughy was also unsure whether intensive care could have helped in saving Mr Hewes’ life, stressing there was not much change in the facilities provided by the ICU. 

He was also backed up by Professor Patrick Nee, a former NHS consultant in intensive care, who believed Mr Hewes was unlikely to have survived

He admitted interventions in Mr Hewes’ state could have commenced an hour earlier, but when pushed by the coroner regarding Mr Hewes’ chances of survival, Professor Nee responded: “Potentially, yes [he could have survived].” But he added: “It’s a leap…to say he would have survived.”

When asked for clarification, Professor Nee said: “I think he probably would not have survived.”

Whilst Mr Hewes reached the hospital just after 12am, he was not given antibiotics until 1.25am, more than an hour after his arrival. 

In a statement read out to the court, Dr Burns claimed that antibiotics were only given to her son because she was present. 

She said: “I raised concern about the lack of antibiotics eight times before they were administered.”

According to the Guardian, the doctor prescribed two grams of the antibiotic ceftriaxone within minutes of Mr Hewes’ arrival, and the medical team knew the drug had to be administered promptly to prevent the worsening of symptoms.

However, the duty emergency registrar, Dr Rebecca McMillan, and the nurses, failed to communicate effectively, which led to the potentially “life-saving” drug not being given within the first hour of treatment.

Lake informed the inquest he realised the medical error had taken place after checking on Mr Hewes’ chart. However, he does not remember Dr Burns chasing him regarding the administration of the antibiotics. 

Dr McMillan fought back tears as she recounted her realisation the drug had not been given by nurses as she had requested. 

She said: “I do recall standing outside the resus room with [nurse Marianela Balatico] where she asked if I was okay and said that I looked really upset when I realised that antibiotics had not been given.

“Ultimately, I don’t know that I was clear who I was directing my instruction to.”

The coroner, Mary Hassel, repeated Balatico’s prior evidence to the court when the nurse acknowledged the instruction to administer Mr Hewes’ antibiotics had “slipped her mind” as she focussed on alleviating his symptoms.

In a statement to the court, Dr Burns said: “The grief will never go away.

“It is impossible to describe adequately…the feelings of betrayal that I feel about William’s death and the aftermath.”

The inquest continues, with the coroner due to give her conclusion on 27th March.