A pediatric consultant has found it impossible to continue her work at the hospital that could not save her son from a sepsis infection, due to the “feelings of betrayal” she harbors toward her medical peers who dismissed her concerns about his treatment mistakes.
William Hewes, a 22-year-old student of history and politics, passed away on January 21, 2023, from meningococcal septicaemia at Homerton Hospital in east London, where his mother, Dr. Deborah Burns, had dedicated over two decades of service.
During the inquest regarding her son’s death, Burns expressed, “Words fail to capture the profound grief of this extraordinary loss and the sense of betrayal I feel surrounding William’s death and the events that followed.”
The Bow coroner’s court learned that Burns had been “unable to work” at the hospital ever since she witnessed a troubling sequence of medical errors while at her son’s bedside.
In a statement presented to the court, she remarked, “Based on what I personally observed and the notes I reviewed, I believe the medical team responsible for William’s care did not monitor him in a clinically effective manner.”
After bringing her son to the hospital’s Accident and Emergency (A&E) department shortly after midnight, Burns persistently requested that medical staff administer crucial antibiotics during the first hour of his treatment. It was revealed during the inquest that these antibiotics were not provided until 1:25 AM, following a “miscommunication” between a doctor and nursing staff.
On the following day, Burns stated: “In regard to the antibiotics, I truly believe they were only finally administered because I was present. I voiced my concerns about the delay eight times prior to their administration.”
Her statement illustrated her growing desperation as she stayed by her son’s side.
She detailed: “William had a single cannula in his left elbow, without a three-way tap, limiting him to one medication at a time. He received fluid, two doses of morphine, and paracetamol before the antibiotics were given. By 1:15 AM, my desperation grew, prompting me to try and push some paracetamol through in order to clear the cannula for the antibiotics.”
Burns mentioned that she found herself in a position of having to assist one of the doctors treating William. “The medical registrar admitted he was unfamiliar with intravenous morphine, so I had to provide him with guidance, motivated by my desire to ensure the antibiotics were administered.”
She also pointed out the delays in moving her son from the hospital’s resuscitation area to intensive care.
Burns noted: “I observed that the doctors in the emergency department were visibly frustrated that the intensive care registrar refused to accept William for transfer. I believe he remained unmonitored and without treatment in resus for an unacceptable length of time.”
She claimed that errors continued in the intensive care unit, stating, “His treatment did not improve until it was far too late. When the decision to intubate was made, I was filled with despair, fearing we would lose him completely as his blood pressure dropped during the procedure.”
She felt compelled to call William’s father—despite their divorce—because she feared he wouldn’t see their son again unless he arrived at the hospital immediately.
Dr. Ron Daniels, an intensive care consultant and founder of the UK Sepsis Trust, testified that Hewes could have been saved had he received antibiotics within minutes, along with an expedited intensive care intervention by two hours.
He informed the court, “If we took 100 22-year-olds in William’s condition, more than half, likely around 70% to 75%, would survive.”
Daniels added, “Based on the evidence I provided, and my 23 years of clinical experience, I firmly believe that had William received timely treatment following established national and international guidelines, he would have had at least a 50% chance of survival.”
Dr. Mathuratha Sivasubramaniam, the on-duty intensive care registrar, initially declined to admit Hewes to the unit, citing signs of his improvement.
Neil Sheldon KC, the barrister representing the Hewes family, questioned the credibility of Sivasubramaniam’s statement. Coroner Mary Hassell explained that Sivasubramaniam could not be cross-examined as she had since left the UK.
Consultant Petr Dlouhy was informed of Hewes’s deteriorating state shortly after 3 AM. He stated in court that had he been notified sooner about the seriousness of Hewes’s condition, he would have recommended an earlier transfer to intensive care.
He said, “If I had been told he was very unwell, displaying a high heart rate, low blood pressure, and already suffering from impaired kidney function, I certainly would have admitted him.”
When asked whether an earlier admission could have saved Hewes, he replied, “I cannot say for certain if it would have made a difference.”
The inquest is ongoing.
