Luke Mclean of the Garden Court Inquests and Inquiries Team represented the bereaved family.
South London Coroner’s Court
Inquest into Death from Sepsis Following Hospital Discharge – Missed Opportunities for Investigation and Treatment
Luke represented the family of a 48-year-old drama therapist who died from septic shock caused by cerebral toxoplasmosis, less than 24 hours after being discharged from hospital.
The inquest examined the circumstances surrounding the deceased’s attendance at the Emergency Department, including whether opportunities had been missed to identify and treat developing sepsis.
A central issue concerned the failure of the treating doctor to review the ambulance handover documentation, which recorded two National Early Warning Scores (NEWS) of 4, significantly elevated respiratory rates and a reduction in systolic blood pressure. The inquest considered whether these observations should have prompted further investigations before the deceased was discharged with a suspected viral infection and tendonitis.
The Coroner found that the deceased was likely already suffering from sepsis when she attended hospital. The Coroner further found that the treating doctor should have considered the ambulance observations and undertaken additional investigations, including blood tests and repeat blood-pressure measurements. Had blood tests been undertaken, they would probably have revealed abnormalities resulting in the deceased remaining in hospital for further investigation and support.
The inquest also considered expert evidence that the deceased was potentially curable at the time of her initial hospital attendance and that approximately 92% of patients with cerebral toxoplasmosis survive. The Coroner identified a missed opportunity to treat the developing sepsis and prevent deterioration into septic shock but was unable to conclude, on the balance of probabilities, that earlier intervention would have prevented death.
The proceedings raised issues concerning clinical decision-making, the communication of pre-hospital observations, causation, neglect, Article 2 of the European Convention on Human Rights (ECHR) and the prevention of future deaths.
Although the Coroner declined to make a finding of neglect, engage Article 2 or issue a Prevention of Future Deaths report, the inquest examined changes introduced by the NHS Trust to improve access to ambulance records and ensure that pre-hospital observations are considered before decisions concerning investigation and discharge.
The case highlights the importance of effective communication between ambulance services and Emergency Departments, particularly where a patient’s physiological observations may indicate developing sepsis.
