Prevention of Future Deaths reports · 2025
Regulation 28 report to prevent future deaths, reference 2025-0163, written 27 Mar 2025. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 27 Mar 2025 |
|---|---|
| Reference | 2025-0163 |
| Deceased | William Hewes |
| Coroner | Mary Hassell |
| Coroner area | Inner North London |
| Category | Hospital Death (Clinical Procedures and medical management) related deaths · Alcohol, drug and medication related deaths |
| Organisation named | Homerton Healthcare NHS Foundation Trust · Homerton University Hospital NHS Trust |
| Source | judiciary.uk record · original PDF |
| Responses published | 1 |
Text extracted from the PDF text layer. Reproduced verbatim, including the scan's own layout.
William David Patrick HEWES - determination on 27.03.25 This has been an inquest on behalf of Our Sovereign Lord The King by me, Mary Elizabeth Hassell, Senior Coroner for Inner North London, touching the death of William David Patrick Hewes, who died on 21 January 2023 at Homerton University Hospital in London. I make a narrative determination as follows. “William Hewes was a 22 year old fit and healthy young man with no co- morbidities, who became unwell at approximately 1.30pm on the afternoon of Friday, 20 January 2023. He felt cold and had a headache. He felt worse during the day. He went to bed for the night at 10.30pm. About an hour later, he got up to tell his mother that he now felt very unwell. He was unable to pass urine and he showed her what he thought was bruising on his belly. William’s mother, a consultant paediatrician, recognised a non blanching rash. She suspected meningococcal sepsis. She rang the emergency department (ED) of the hospital where she worked, to warn them that she and her son would arrive shortly. She explained to the ED registrar that she was a consultant paediatrician at that hospital, she described her son’s signs and symptoms and she said she thought he had meningococcal sepsis. Mother and son left home without delay and arrived at the hospital at 12.06am on the morning of Saturday, 21 January 2023. William was triaged and then medically assessed promptly. His mother immediately articulated the requirement for antibiotics. By the time of his assessment in hospital, William had an almost eleven hour history of being unwell. He had non blanching rashes and cold peripheries. He was hypotensive (systolic blood pressure of 85), tachycardic (heart rate of 119) and acidotic (venous lactate of 7.2). He was actively vomiting, he had a severe headache and he was in intense pain in his right flank. He was still alert and speaking. He was immediately recognised by all medical and nursing staff with care of him as a patient with life threatening sepsis. The ED registrar who assessed William gave an instruction for ondansetron (an anti sickness medication), Hartmann’s solution (to replace body fluid), morphine (for pain relief) and paracetamol (to lower his temperature). She then checked the correct antibiotic and dose, and also gave an instruction that ceftriaxone (an antibiotic) and acyclovir (an antiviral) be given. All these instructions were given verbally, an acceptable method of prescribing drugs in an emergency situation, with the doctor writing up the prescriptions in the medical record a little later. However, although the ondansetron, Hartmann’s, morphine and paracetamol verbal instructions were given one-to-one (ED registrar to William’s ED resuscitation nurse), the ED registrar gave the ceftriaxone and acyclovir verbal instructions when two nurses were present and she did not address either nurse by name. Neither nurse heard the instruction and neither nurse responded. The loop of communication was not closed. William’s ED resuscitation nurse was aware that he was suffering from sepsis. She was aware of the sepsis six bundle. She was aware that a patient with sepsis should be given an antibiotic immediately and in any event within one hour. She did not ask the ED registrar about giving William an antibiotic. The verbal drug instructions were all issued between 12.31am and 12.35am. William’s ED resuscitation nurse gave the ondansetron, Hartmann’s, morphine and paracetamol. When the nurse was administering these drugs, William’s mother, known by the nurse to be a consultant paediatrician at that hospital, asked the nurse if she was administering the antibiotic. The nurse said yes, though as far as the nurse was aware an antibiotic had not even been prescribed let alone administered. The nurse was not being deliberately untruthful, but she did not listen properly to what she was being asked and so she gave entirely the wrong answer. The first litre of Hartmann’s went up at 12.50am. At 1.15am, a medical registrar came to assist the ED registrar. It was after his attendance that the discovery was made that the antibiotic and the antiviral had not been given. The ceftriaxone and acyclovir were then administered at 1.25pm. Following the administration of the first litre of fluid, there was a transient increase in blood pressure and drop in heart rate, but it was not sustained. The second litre of Hartmann’s went up at 1.30am. Between approximately 2.05 and 2.10am, the medical registrar asked for William to be catheterised. When William had not passed urine by 2.20am, the medical registrar asked for a third litre of fluid to be administered. The ED registrar had promptly asked for an intensive care consultation with a view to transferring William to the intensive treatment unit (ITU), making the request even before she had called the medical registrar. The ITU registrar assessed William at 1.38am. She did not accept him for transfer to the ITU. Transferring William to intensive care would have provided one-to-one nursing from a skilled ITU nurse. However, the other treatment that he would have been given in intensive care, such as an arterial line, frequent blood gases, an early urinary catheter and fluid challenge, were available in the ED resuscitation unit. Whilst the ED registrar was of the firm view that William needed transfer to ITU and she would have much preferred this to take place as soon as possible, she also thought that the ITU registrar’s decision not to transfer at that time was reasonable. There was therefore no strong disagreement between the teams at that stage and so it was not mandatory for the ITU registrar to call her ITU consultant after she saw William at 1.38am. At 2.42am, the ED registrar asked the ITU registrar to return to the ED resuscitation unit, pointing out that William had now developed an oxygen requirement and had no urine output. The ITU registrar did return, although only after a robust conversation between them and after the ED registrar had obtained the medical registrar’s support for her request. The three teams all knew the plan for William of fluids, medication and blood cultures, but there was no clear record made of a plan for the timing and quantity of fluids to be given, and between 1.20am and decision to transfer to ITU it was not clear whether the ED registrar, the medical registrar or the ITU registrar had ultimate oversight of William’s care. The decision to transfer to ITU was made at 3.09am. William was then transferred swiftly, arriving at 4am. Thus the national standard of a maximum of four hours to transfer in such a situation was not breached. With hindsight, by then his condition was probably irretrievable. William Hewes died at 2.22pm on Saturday, 21 January 2023, from invasive meningococcal septicaemia, a natural cause of death. When he attended hospital just after midnight on the day he died, William’s life threatening condition was recognised, but he did not receive immediate antibiotics, immediate and repeated fluid boluses with repeated reassessment of capillary refill, heart rate, blood pressure and serial lactate measurement after each intervention, then vasopressors or inotropes, followed by early haemofiltration if needed, with the urgency that he should have. However, he was already very unwell when arrived, and it is unclear whether, if he had been administered all appropriate treatment promptly, his life would have been saved.” I intend to make a prevention of future deaths report. That concludes this inquest.
Regulation 28: Prevention of Future Deaths report
William David Patrick HEWES (died 21.01.23)
THIS REPORT IS BEING SENT TO:
1. Medical Director
Homerton University Hospital NHS Trust
Homerton Row
London E9 6SR
1
CORONER
I am: Coroner ME Hassell
Senior Coroner
Inner North London
St Pancras Coroner’s Court
Camley Street
London N1C 4PP
2
CORONER’S LEGAL POWERS
I make this report under the Coroners and Justice Act 2009,
paragraph 7, Schedule 5, and
The Coroners (Investigations) Regulations 2013,
regulations 28 and 29.
3
INVESTIGATION and INQUEST
On 25 January 2023, I commenced an investigation into the death of
William Hewes aged 22 years. The investigation concluded at the end
of the inquest earlier today. I made a narrative determination, which I
attach.
4
CIRCUMSTANCES OF THE DEATH
William was a fit and healthy young man who died from meningococcal
septicaemia.
5
CORONER’S CONCERNS
1
During the course of the inquest, the evidence revealed matters giving
rise to concern. In my opinion, there is a risk that future deaths will occur
unless action is taken. In the circumstances, it is my statutory duty to
report to you.
The MATTERS OF CONCERN are as follows.
William’s life threatening condition was recognised immediately he
attended hospital, but he did not receive the necessary treatment as
promptly as he should have done. The cause of the delay was multi
factorial.
I heard at inquest that the Homerton University Hospital NHS Trust has
done a great deal of work since William’s death to try to avoid this sort of
situation arising in the future.
If future patients at the Homerton can benefit from William’s death, then
why not future patients elsewhere? It seems to me that there would be
great merit in sharing the learning nationally.
6
ACTION SHOULD BE TAKEN
In my opinion, action should be taken to prevent future deaths and I
believe that you have the power to take such action.
7
YOUR RESPONSE
You are under a duty to respond to this report within 56 days of the date
of this report, namely by 26 May 2025. I, the coroner, may extend the
period.
Your response must contain details of action taken or proposed to be
taken, setting out the timetable for action. Otherwise, you must explain
why no action is proposed.
8
COPIES and PUBLICATION
I have sent a copy of my report to the following.
• The mother of William Hewes
• The father of William Hewes
• The Care Quality Commission for England
• HHJ Alexia Durran, the Chief Coroner of England & Wales
I am also under a duty to send a copy of your response to the Chief
Coroner and all interested persons who in my opinion should receive it.
2
I may also send a copy of your response to any other person who I
believe may find it useful or of interest.
The Chief Coroner may publish either or both in a complete or redacted
or summary form. She may send a copy of this report to any person who
she believes may find it useful or of interest. You may make
representations to me, the coroner, at the time of your response, about
the release or the publication of your response.
9
DATE SIGNED BY SENIOR CORONER
27.03.25 ME Hassell
3
1 response published against this report on judiciary.uk. A response is a body's written reply to the coroner's concerns; publication is at the discretion of the Chief Coroner's office, so an absent response does not mean nobody replied.
Homerton Healthcare NHS Foundation Trust Homerton Row London E9 6SR www.homerton.nhs.uk Ms ME Hassell HM Senior Coroner Inner North London St Pancras Coroner’s Court Camley Street London N1C 4PP 13 May 2025 Dear Madam, Re: Regulation 28 Report to Prevent Future Deaths I write in response to the Regulation 28 Report to Prevent Future Deaths dated 27 March 2025 issued to Homerton Healthcare NHS Foundation Trust (‘the Trust’) following the inquest touching the death of William David Patrick Hewes. This response has been prepared with input from the Chief Nurse and various members of the Emergency Medicine and Intensive Care teams. We express our sincere condolences to the family and loved ones of William. We take the concerns raised in the Regulation 28 Report seriously and are committed to taking appropriate action to prevent similar occurrences in the future. In the report, you have raised the following: 1) William’s life-threatening condition was recognised immediately he attended hospital, but he did not receive the necessary treatment as promptly as he should have done. The cause of the delay was multi factorial. 2) I heard at inquest that the Homerton University Hospital NHS Trust has done a great deal of work since William’s death to try to avoid this sort of situation arising in the future. 3) If future patients at the Homerton can benefit from William’s death, then why not future patients elsewhere? It seems to me that there would be great merit in sharing the learning nationally. Action should be taken to prevent future deaths In order to share the learning nationally the Trust have taken and are proposing the following actions: 1) The Trust are one of the pilot sites for the first phase in implementing Martha’s Rule. This is a major patient safety initiative providing patients and families with a way to seek an urgent review if they are concerned about a loved one’s deterioration. Part of this first phase is to help the NHS to devise and agree a standardised approach to all three elements of Martha’s Rule (ahead of scaling up to further sites in England in the following years). Once fully Incorporating hospital and community health services, teaching and research - 2 - implemented, patients, families, carers and staff will have round-the-clock access to a rapid review from a team skilled in managing deterioration if they are worried about a person’s condition as well as being asked on a routine basis about how they are feeling. As part of the pilot programme, we are regularly meeting with other pilot sites and sharing the lessons learnt during the implementation of the programme. This learning, alongside our data, is being shared with NHS England to help inform nationwide implementation of Martha’s Rule. This pilot is ongoing (started in May 2024). 2) One of our local actions was to deliver SIM (simulation) training to clinical staff. Simulation training is a tool used to gain practical experience, make informed decisions and refine their performance within controlled settings. The SIM training is focused on ensuring closed loop communication / direct instruction to team members when managing sepsis and shock in emergency situations. The plan is to develop this and deliver it on our Regional Trainee Teaching programme to resident doctors on managing human factors within healthcare. This course runs regularly throughout the year, we are aiming to incorporate the learning on closed loop communication into the next programme. The training runs 3 to 4 times a year. 3) Share the success of the RESPOND training programme at Regional and National conferences / meeting – the RESPOND programme provides training for nurses and nursing associates working in adult areas to support and develop knowledge and understanding in recognising early signs and need of the deteriorating patients including those with sepsis. 4) In agreement and in collaboration with William’s family share “William’s Story” at National and Regional Patient Safety meetings to support and promote learning on managing sepsis, recognition of deterioration and listening to families. We hope that this information provides you with the appropriate assurance that we have taken these issues seriously and are determined to implement effective changes to prevent future deaths. We trust that the above actions and learning can be shared more widely to support improvements elsewhere. I would like to reiterate our sincere condolences to William’s family and express our commitment to learning from this tragic event. Yours sincerely Chief Executive Officer and Place Based Leader
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