PRINCE EVANS ACHIEVE SUCCESSFUL OUTCOME FOLLOWING INQUEST INTO SEPSIS DEATH

Gary Smith, Partner and Head of Prince Evans Personal and Clinical Negligence Department, has recently successfully represented the interests of the family of the late Mr Michael Allen at Milton Keynes Coroners Court, in circumstances where the Trust initially asserted Mr Allen died of natural causes. 

Mr Allen was an otherwise healthy 56 year old who was admitted to Milton Keynes Hospital on 3 April 2021 with gallstone pancreatitis. Imaging confirmed the stones within his gallbladder were causing an obstruction. His treating surgeons proposed an Endoscopic Retrograde Cholangio Pancreatography (ERCP) procedure. The technique involved an endoscopy, a thin tube containing a small camera, being passed through Mr Allen’s mouth to gain access to the gallbladder. Prior to the procedure, Mr Allen was given prophylactic antibiotics, intended to prevent the risk of infection arising from the surgery. 

Superficially, the ERCP procedure went well and without observed difficulty. A small cut was made to facilitate passage of a 6mm stone, and the obstruction was successfully removed. 

The procedure, however, carries an established risk of bacterial infection and in the subsequent hours, Mr Allen’s condition began to deteriorate. Post-surgery he was observed in accordance with the national standardised mechanism, known as the National Early Warning Score system (NEWS2) This monitors physiological parameters such as respiration rate, oxygen saturation (balance of oxygen in blood), systolic blood pressure, pulse rate, and temperature. The very purpose of NEWS2 is to identify and provide early warning of objective deterioration of patients in circumstances where they might otherwise appear visibly well. 

At 06:30 on 9 April 2021, Mr Allen’s NEWS2 parameters deteriorated. His blood oxygen levels de-saturated, and his pulse rate and blood pressure increased. His scores were such that, in accordance with the NEWS2 protocol, he ought to have been urgently reviewed to determine the cause of his deterioration, with escalation of monitoring and clinical care. 

He was first reviewed at 08:00 at a routine ward round. Whilst the escalated NEWS2 scores were noted, neither the sepsis protocols or NEWS2 escalation of care protocols were engaged. 

By 10:00, Mr Allen had deteriorated further. It was plain that he was a “sick or deteriorating patient”, and there were one or more red flags that ought to have escalated his care and treatment resulting to an admission to critical care. 

This did not happen. Further, despite objective evidence of infection in the presence of prophylactic antibiotics (which were plainly not effective as he was deteriorating) no consideration was given to changing his antibiotics to enhanced broad spectrum antibiotics. 

Mr Allen was not observed clinically at all between 14:28 and 18:05. At 18:05, his condition significantly deteriorated. He was admitted to the Trust’s Intensive Therapy Unit (ITU) at circa 19:00. He had suffered multi-organ failure. His prospects of survival had, by this stage, significantly declined. His antibiotics were changed, but it was too late. Mr Allen died on 11 April 2021. 

Milton Keynes Hospital Trust initially contended that Mr Allen unexpectedly deteriorated and died of natural causes. An enquiry into his death was conducted by HM Assistant Coroner Dr Sean Cummings and Milton Keynes Coroners Court, where the family were represented by Gary Smith of Prince Evans and Counsel, Mr Edward Ramsay of 12 King’s Bench Walk Chambers. 

A link to the Coroner’s full findings and conclusion can be found here. Dr Cummings found that whilst all clinicians were aware of the MKUH Sepsis Protocol, “none of them was able to describe it fully” and that “as a result there was a failure to initiate the Sepsis Protocol effectively”. He further found, “there was a failure to effectively and constantly monitor Mr Allen” and that when he deteriorated at 18:00 “there was a further delay of one hour before the ITU team were called”. 

Overall, he concluded “the surgical team in charge of Mr Allen had no effective knowledge of the Sepsis protocol….failed to monitor him effectively or consistently despite clear signs of deterioration… failed to provide adequate support and supervision….failed to institute an effective senior review at any point on 9 April 2021 until critical deterioration by which time his chances of death due to his rapid deterioration and multi-organ failure were 80-100%”. 

HM Coroner Cummings ultimate conclusion was, “had he been effectively monitored and subject to senior surgical supervision during 9 April 2021 it was more likely than not that he would have survived”. 

Despite these conclusions, whilst the hospital Trust admitted breaches of duty it denied causation, asserting that even if the protocols had been followed and appropriate treatment was provided, Mr Allen would have died. 

Comprehensive Expert Consultant Intensive Care evidence was commissioned by Prince Evans from one of the country’s leading Consultant Intensivists, who was very dismissive of the Trust’s contentions. The case settled on terms that the family were compensated for their  dependency upon Mr Allen. 

Case Comment – Gary Smith

“Unfortunately, in my experience the circumstance are tragically all too common. Sepsis is a life-threatening condition. The UK Sepsis Trust report that approximately 49,735 lives are lost each year due to Sepsis, and that nearly 80,000 of survivors are left with life-changing after effects. 
It is imperative that Sepsis is recognised and treated early; time, very much is of the essence. However, it is not uncommon to find often under resourced professionals failing to follow  mandatory life-saving protocols such as NEW2 and Sepsis 6. In instances where there is suspicion early intervention was not provided, I would recommend that experienced legal advice is sought”.