A consultant pediatrician informed her medical colleagues treating her son that they neglected to administer critical antibiotics hours before he succumbed to sepsis, as revealed during an inquest.
William Hewes, aged 22 and a 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, is employed.
Dr. Burns brought her “critically unwell” son to the hospital’s A&E shortly after midnight, alerting her colleagues that he required immediate treatment for meningitis, the inquest into his demise disclosed on Thursday.
A physician prescribed 2 grams of ceftriaxone, an antibiotic, moments after Hewes arrived, and the medical team recognized the urgency of administering the medication promptly. However, a miscommunication between the on-duty emergency registrar, Dr. Rebecca McMillan, and the nursing staff resulted in the essential medication not being given within the crucial first hour of treatment, according to the inquest.
Burns stated that her son only received the antibiotics after she informed Dr. Luke Lake, the acting medical registrar on duty, of the oversight. In written testimony presented to the court, she recounted, “I told him I was unsure if William had been given the antibiotics. Luke reassured me that the medication had been prescribed earlier. I responded, ‘Yes, but it hasn’t been administered.’”
Dr. Lake acknowledged during the inquest that he had realized the mistake with the antibiotic after reviewing Hewes’s chart. However, when questioned by the family’s lawyer, Neil Sheldon KC, he conceded, “The truth is that Dr. Burns did encourage you to verify whether the antibiotics had been given, and it wasn’t something you had independently checked.”
Lake countered, “That’s not my recollection. She might have prompted me. I can’t recall with complete clarity.”
Earlier in the proceedings, McMillan recounted her distress upon realizing around 1:17 AM that the nurses had not given the requested antibiotics.
“I distinctly remember standing outside the resuscitation room with [nurse Marianela Balatico] when she asked if I was alright, noting that I looked quite upset after realizing the antibiotics had not been administered. We expressed our confusion about how this oversight occurred, both feeling dismayed once we recognized it hadn’t been done,” McMillan said.
Holding back tears, she expressed that one of the critical lessons from Hewes’s case was the necessity of being clearer about whom she was instructing. She added, “I believed my instructions were sufficiently clear. I’ve replayed that moment in my mind countless times.”
Coroner Mary Hassell recounted Balatico’s earlier testimony in which the nurse admitted that the directive to give antibiotics to Hewes had “slipped my mind” amidst her focus on alleviating his symptoms.
The court also heard that the medical team faced disputes regarding the timing of Hewes’s transfer to the intensive care unit after his condition worsened. McMillan noted feeling the need to plead with Dr. Mathuratha Sivasubramaniam, the intensive care registrar in charge of admissions.
Sivasubramanian recommended that Hewes’s treatment continue in the emergency unit pending further evaluation before an admission to intensive care.
The coroner remarked, “It sounds like an argument,” to which McMillan replied, “She wasn’t responding with the same urgency I was expressing.”
McMillan further indicated that there was a lack of clarity among the three doctors about who was responsible for Hewes’s care, expressing concern: “My anxiety is that it wasn’t entirely clear among the three of us who had overall responsibility for William’s care.”
The inquest is ongoing.
