Prevention of Future Deaths reports · 2026
Regulation 28 report to prevent future deaths, reference 2026-0273, written 8 May 2026. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 8 May 2026 |
|---|---|
| Reference | 2026-0273 |
| Deceased | Garth Pretorius |
| Coroner | Paul Marks |
| Coroner area | East Riding of Yorkshire and City of Kingston Upon Hull |
| Source | judiciary.uk record |
| Responses published | 1 |
Text extracted from the PDF text layer. Reproduced verbatim, including the scan's own layout.
ANNEX A REGULATION 28: REPORT TO PREVENT FUTURE DEATHS (1) NOTE: This form is to be used after an inquest. REGULATION 28 REPORT TO PREVENT FUTURE DEATHS THIS REPORT IS BEING SENT TO: 1. Chief Executive HUTH 1 CORONER I am Professor Paul Marks, Senior Coroner, for the Coroner Area of City of Kingston Upon Hull and the County of the East Riding of Yorkshire. 2 CORONER’S LEGAL POWERS I make this report under paragraph 7, Schedule 5, of the Coroners and Justice Act 2009 and regulations 28 and 29 of the Coroners (Investigations) Regulations 2013. 3 INVESTIGATION and INQUEST On 6th January 2026, I commenced an investigation into the death of Garth Pretorius, aged 36 years. The investigation concluded at the end of the inquest on 1st May 2026, the narrative conclusion of the inquest was:- Garth Pretorius underwent a microdissection testicular sperm extraction procedure on 19th December 2024 due to azoospermia consequent on Klinefelter's syndrome. The procedure was uneventful but just over a week later, he became unwell and presented to the out of hours service at Goole Urgent Treatment Centre. He was found to have red flags for sepsis and was told to attend the Emergency Department at Hull Royal Infirmary. Despite the diagnosis of sepsis being made at `Goole, the Sepsis 6 pathway was not instituted and due to confusion over the arrival of an impending emergency at Hull Royal Infirmary, Garth Pretorius and 15 other patients were effectively told to leave the department. As a result of this, there was a delay of approximately 24 hours in commencing appropriate treatment for sepsis which is a time sensitive condition. This delay more than minimally, negligibly or trivially contributed to Garth's death at Castle Hill Hospital on 3rd January 2025. 4 CIRCUMSTANCES OF THE DEATH Please see attached findings of fact. 1 5 CORONER’S CONCERNS 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. – Evidence was heard from the Court’s independent expert that it is unacceptable for two different triage systems to be employed simultaneously in the Emergency Department of Hull Royal Infirmary. Professor Fletcher gave evidence that the Manchester system is validated and internationally accepted, but at material times, another system was used and continues to be used. Some practitioners use the Manchester system whilst others use a different system. Evidence was heard that the use of the Manchester system requires training and there do not appear to be sufficient resources still available for it to be adopted universally at Hull Royal Infirmary. 6 ACTION SHOULD BE TAKEN In my opinion action should be taken to prevent future deaths and I believe you and your organisation has the power to take such action. This may include, for example, allocating the necessary resources to fast track the universal adoption of the Manchester Triage System in the Trust. 7 YOUR RESPONSE You are under a duty to respond to this report within 56 days of the date of this report, namely by 3rd July 2026. 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 Chief Coroner and to the following Interested Persons NHS England and equivalent organisations in the other countries of the United Kingdom. . I am also sending a copy to I am also under a duty to send the Chief Coroner a copy of your response. The Chief Coroner may publish either or both in a complete or redacted or summary form. He may send a copy of this report to any person who he 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 by the Chief Coroner. 9 PV Marks H.M. Senior Coroner 8th May 2026 2
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.
Hull Royal Infirmary Anlaby Road, Hull, HU3 2JZ 10 July 2026 Professor Paul Marks Senior Coroner for Hull and the East Riding The Coroner’s Court & Offices The Guildhall Alfred Gelder Street Hull HU1 2AA Dear Professor Marks, Re: Regulation 28 Report to Prevent Future Deaths – Garth Pretorious We write in response to your Regulation 28 Report dated 8 May 2026. Firstly, we would like to express our sincere condolences to Mr Pretorius’s family for their loss. We recognise the importance of responding fully to the concerns raised. We note the Coroner’s concern that two different triage approaches are being used within the Emergency Department at Hull Royal Infirmary, and the associated risk to patient safety if there is inconsistency in the application of triage processes. The Trust acknowledges the importance of a consistent, reliable and evidence-based approach to triage. In response, we confirm the following: Implementation of the Manchester Triage System The Trust is strengthening the consistent application of the Manchester Triage System through an expanded programme of training and assessment. Clinical Nurse Educators are actively delivering this programme to ensure that all staff undertaking triage are appropriately trained and competent in the use of the system. Progress is being made to ensure improved consistency and reliability in triage decision-making. Training in the Manchester Triage System is being delivered to 155 members of staff through a comprehensive three-stage programme comprising e-learning, a face-to-face workshop, and Working in partnership: Hull University Teaching Hospitals NHS Trust Northern Lincolnshire and Goole NHS Foundation Trust United by Compassion: Driving for Excellence a final competency sign-off. This robust training pathway has been designed to ensure staff develop and demonstrate the knowledge and skills required to undertake triage safely and effectively. Currently, 42% of the workforce has completed the training programme in some capacity. Given the size of the workforce and the requirement to maintain operational service provision, achieving full compliance represents a considerable organisational challenge. Nevertheless, a phased implementation plan is in place, and the organisation remains on track to have all staff trained and signed off as competent by the end of the year. Role of Senior Clinical Assessment Where operationally feasible, the Trust positions senior clinical decision-makers at the front door of the Emergency Department between 08:00 and 00:00. These clinicians (Emergency Medicine Consultants or Higher Specialty Trainees) provide early senior assessment, which is known to improve safety, patient flow and clinical decision- making. In these circumstances, triage categorisation may be undertaken through immediate senior clinical assessment rather than formal application of the Manchester Triage System. This approach reflects the principle that the Manchester Triage System is intended to support, rather than replace, senior clinical judgement and experience. Ensuring Safe and Consistent Practice The Trust recognises that variation in practice must be minimised. The expanded training programme and focus on competency assessment are intended to ensure that all staff understand the appropriate use of the Manchester system alongside clinical judgement. This work is ongoing and forms a key part of improving the consistency, safety and reliability of triage processes within the Emergency Department. The Trust has taken, and continues to take, substantive action to ensure the universal, reliable application of the Manchester Triage System, supported by training, governance and audit. In parallel, we are addressing wider systemic factors identified through detailed investigation, including emergency department flow, communication, recognition of deterioration, and the timely management of sepsis. We are committed to ensuring that these actions are embedded, monitored and sustained, and that the learning from Mr Pretorius’s death leads to meaningful improvements in the safety and quality of care provided to patients. Yours sincerely Group Chief Executive
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