A 36-year-old man died from sepsis after being told to leave an emergency department due to overcrowding, despite displaying critical warning signs, an inquest has revealed.
Garth Pretorious underwent a routine fertility procedure on December 19, 2024. A week later, he fell ill and sought help at Goole Urgent Treatment Centre, where he was triaged and identified as having 'red flag' indicators for sepsis. These symptoms can include confusion, slurred speech, muscle pain, difficulty breathing, and pale skin, lips, or tongue.
Despite the life-threatening nature of sepsis, which can lead to organ failure, Mr. Pretorious was redirected to the A&E department at Hull Royal Infirmary. At the emergency department, the "Sepsis 6 pathway"—a critical treatment protocol involving specific tests and interventions to rapidly restore blood flow and oxygen to vital organs—was not initiated. Professor Paul Marks, the senior coroner overseeing the case, stated at the inquest that this pathway should be triggered within an hour of a sepsis diagnosis.
The inquest heard that due to "confusion over the arrival of an impending emergency at Hull Royal Infirmary," Mr. Pretorious, along with 15 other patients, were effectively asked to leave the department. This resulted in a delay of approximately 24 hours before appropriate sepsis treatment could commence. Professor Marks concluded that this delay "more than minimally, negligibly or trivially contributed" to Mr. Pretorious's death on January 3, 2025, at Castle Hill Hospital.
Sepsis typically develops rapidly from a bacterial infection, occurring when the body's immune system overreacts, triggering severe responses that can cause organ failure. The UK Sepsis Trust estimates that thousands of the 48,000 annual deaths attributed to sepsis-related illnesses could be prevented. For every hour of delayed treatment, the risk of death increases by up to eight percent.
Recognizing sepsis can be challenging, particularly in infants and young children. Symptoms in this age group may include difficulty breathing, fast breathing, seizures, high or low temperature, unusual sleepiness or difficulty waking, and changes in urinary habits. Babies and young children may also show a lack of interest in feeding or be repetitively sick.
In adults, symptoms can include slurred speech, uncontrollable shivering, and a low temperature. However, experts note that not all individuals may present with every symptom. Immediate medical attention is required for anyone suspecting sepsis, with antibiotics ideally administered within an hour of hospital arrival.
NHS figures indicate over 118,000 emergency admissions for sepsis in 2024-25. The inquest also found that two different triage systems were in use when Mr. Pretorious arrived at the emergency department. Experts suggest this contributed significantly to his death and warned that further fatalities may occur without corrective action. Professor Marks noted that one of the systems, the Manchester System, required training that the hospital reportedly lacked the resources to implement appropriately.
Following the release of the report, medical professionals described the findings as "grim" and "awful." In response to the challenges in sepsis detection, the NHS is planning to deploy wearable sensors to help identify symptoms and aims to reduce sepsis deaths by a quarter by 2035.