It is not possible to say whether a fit and healthy student who died in hospital with sepsis would have survived if he had been treated earlier, a coroner has ruled.
William Hewes, 22, died at Homerton University Hospital (HUH) on January 21 2023 within 24 hours of being admitted after his meningitis, caused by a meningococcal infection, developed into sepsis.
The 6ft 6ins history and politics student was rushed to HUH by his mother, consultant paediatrician Deborah Burns, who was a doctor at the same east London hospital for more than 20 years.
An inquest in February at Bow Coroner’s Court heard medical staff failed to administer antibiotics swiftly to Mr Hewes and Dr Burns said her son was “left unmonitored and untreated in resus for far too long”, and that his care “was no better on the ICU until it was too late”.
In a narrative conclusion delivered on Thursday, senior coroner Mary Hassell gave the medical cause of death as meningococcal septicaemia.
The coroner also said “he was already very unwell when he arrived and it is unclear whether if he had been administered all appropriate treatment promptly, his life would have been saved”.
In a statement on Thursday, Dr Burns said: “I hope that the outcome of the coroner’s inquest can lead to learning and improvement to the care of people with sepsis in the future.”
She added: “On the night I took William to hospital I knew he needed antibiotics as soon as possible but I witnessed a delay.
“In all, I raised the alarm eight times. On one occasion I was told the antibiotics had been given when they had not.”
She added: “My pursuit of the truth is not about blame. It has always been driven by concerns about the standard of care I witnessed in my own emergency department.”
The coroner said “the real area of contention” is whether earlier treatment would have changed the outcome.
The inquest heard expert witnesses gave differing opinions, backed by data, relating to Mr Hewes’ chances of survival if he had been treated earlier.
The coroner explained: “I have thought carefully about each opinion, which I find were honestly and at times passionately given, but ultimately I am not persuaded by either. What I conclude is not that I cannot choose between them. It is that I choose neither.
“I am not convinced, even on the balance of probabilities, that the state of medical knowledge is such that we know the answer to the question of whether William would have survived had he received earlier treatment when he got to hospital.”
Mr Hewes became unwell at approximately 1.30pm on January 20 and said he felt cold and had a headache.
He felt worse during the day and got up after going to bed that night to tell his mother that he now felt very unwell and had bruising on his belly.
His mother suspected meningococcal sepsis, rang the hospital emergency department and warned them she and her son were on their way.
She described her son’s signs and symptoms, and he was then “medically assessed promptly”, the coroner said.
She added: “By the time of his assessment in hospital, William had an almost 11-hour history of being unwell.”
He was still alert and speaking but presented with a range of issues, including active vomiting, severe headache and intense pain in his right flank.
All the medical and nursing staff who cared for him “immediately recognised” that he was “a patient with life-threatening sepsis”, the coroner said.
The decision to transfer to ITU was made at 3.09am and Mr Hewes arrived there at 4am.
The coroner noted that “the national standard of a maximum of four hours to transfer in such a situation was not breached”, but added “with hindsight, by then, his condition was probably irretrievable”.
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