During an inquest, it was revealed that a physician, whose son succumbed to sepsis at the hospital where she was employed, had requested antibiotics on eight separate occasions before they were finally administered.
William Hewes, 22, tragically passed away at Homerton University Hospital in east London in January 2023, less than a day after being admitted for meningitis, which escalated into sepsis due to a meningococcal infection.
The proceedings at Bow Coroner’s Court have already disclosed that medical personnel failed to provide him with antibiotics within the hour of his arrival, contravening national protocols.
Dr. Deborah Burns stated in her testimony, “I am convinced that [the antibiotics] were ultimately administered because I was present.”
She further mentioned, “I voiced my concerns regarding the absence of antibiotics on eight occasions prior to their administration.”
Dr. Burns also expressed her view that her son was “left unobserved and untreated in the resuscitation area for an excessive duration” and noted that his treatment “was not improved on the ICU until it was far too late.”
William arrived at the hospital at 00:06 GMT and was taken to the emergency resuscitation area, where he did not receive antibiotics until approximately 01:25—over an hour after his admission.
Initially, he was equipped with a single canula in his left arm, which could only deliver one medication at a time, as noted in court.
He received anti-nausea medication, pain relief, and fluids before the antibiotics were finally provided.
Dr. Burns recorded that by 01:15, she had “become extremely anxious” and attempted to “administer some of the paracetamol to clear the canula for other medications.”
She stated she was not informed when the antibiotics were finally given.
The inquest revealed that the delay in administering antibiotics to Mr. Hewes was attributed to failures in communication.
Dr. Rebecca McMillan, the emergency medicine registrar on duty that night, mentioned that she had communicated Mr. Hewes’ need for antibiotics to two nurses, Matthew Potts and Marianela Balatico, upon his arrival in the resuscitation unit.
“I ultimately wasn’t clear on who I was instructing,” she commented.
Coroner Mary Hassell recounted previous evidence from Ms. Balatico, who indicated that her focus was on alleviating Mr. Hewes’ symptoms and that “the antibiotics slipped my mind.”
The court was informed that Dr. Burns noted in her statement that she had raised her concerns regarding her son’s lack of antibiotics with various medical staff multiple times.
Dr. Luke Lake, the medical registrar on call that night, acknowledged that Dr. Burns may have inquired about the antibiotics after he had already addressed it with other personnel.
Dr. McMillan mentioned she did not recall Dr. Burns raising the issue of the antibiotics at that time.
In her court statement, Dr. Burns emphasized, “The grief will never dissipate. It is impossible to fully articulate the sense of betrayal I feel regarding William’s passing and its aftermath.”
Dr. Petr Dlouhy, the intensive care unit (ICU) consultant on duty that night, informed the inquest that Mr. Hewes should have been transferred to intensive care sooner, given his decline into multiple organ failure.
Dr. Mathuratha Sivasubramaniam, the ICU registrar whose statement was read in court, noted that, upon her initial assessment of Mr. Hewes’ condition around 01:09, admission to intensive care was “not necessary” as he seemed to be responding to treatment and showing signs of improvement.
She clarified that the decision to continue administering fluids and medications in resuscitation was made collectively with Dr. Lake and Dr. McMillan.
Dr. Lake indicated he made several calls to the ICU registrar, requesting the transfer of Mr. Hewes to intensive care around 01:50 and 02:00.
Additionally, the senior charge nurse, Mr. Luke Brown, had to call intensive care as Dr. McMillan felt her request at 02:30 was not treated with sufficient urgency and the ICU registrar had not returned to assess Mr. Hewes.
Dr. McMillan testified that, at that moment, Mr. Hewes had become reliant on oxygen support, his vision was “deteriorating,” and his urine output was alarmingly low, leading her to suspect kidney failure.
“It was evident that she was returning,” she stated, “but I felt she was not responding with the same urgency as I was. I was worried about the timing.”
Dr. Dlouhy relayed that shortly after 03:00, he received a call from Dr. Sivasubramaniam regarding Mr. Hewes’ potential admission to intensive care.
“She should have contacted me sooner,” he remarked.
He asserted that had he been aware of Mr. Hewes’ grave condition, including signs of severe illness and organ failures, he would have certainly admitted him before 03:00.
However, he noted that the only differences in care between intensive care and the resuscitation unit would involve more continuous monitoring of blood pressure, closer observation of fluid intake, and possibly earlier blood filtration.
When the coroner inquired if this could have saved Mr. Hewes’ life, he replied, “I genuinely don’t know.”
The inquest is ongoing.
Further reporting is provided by PA Media.
