Essex man died from sepsis after hospital discharge, coroner finds
A coroner’s report highlights missed sepsis signs and systemic failures in the case of David Fenn
David Fenn, a 68-year-old from Essex, died from sepsis following septic arthritis of the left knee, after being sent home from Colchester General Hospital.
A coroner's report suggests that Fenn might have survived if the signs of sepsis were identified before his hospital discharge.
Fenn was treated at the hospital on 28th January but was discharged, and an inquest found he could possibly have survived if urgent knee surgery had been performed instead.
Lincoln Brookes, senior coroner for Essex, published a report on preventing future deaths, identifying several concerns, such as poor mobile phone signal causing crucial information to be missed.
Though Fenn underwent urgent surgery on 2nd February and received intensive care support including antibiotics for severe sepsis, he continued to deteriorate.
Errors noted include the failure to recognize sepsis signs, non-adherence to treatment pathways, and lack of early consultant review.
A junior doctor reportedly did not feel able to challenge the consultant's discharge decision nor sought an alternative opinion.
The Multi Disciplinary Team meeting the morning after did not discuss Fenn's case, despite it needing attention.
The hospital admitted that, with hindsight, the Sepsis 6 pathway should have been followed, and urgent knee surgery performed.
However, the court ruled it could not definitively state Fenn would have survived, only acknowledging the possibility if he had not been discharged.
Catherine Morgan, Chief Nurse at East Suffolk and North Essex NHS Foundation Trust, stated:
“We would like to extend our sincere and deepest sympathies to Mr Fenn’s loved ones for their loss. Providing safe, compassionate care is our highest priority, and we take the concerns raised in the Prevention of Future Deaths report extremely seriously.
Before the inquest, our teams conducted a thorough review of the care Mr Fenn received. We have already made changes to strengthen our clinical processes and communication. We will monitor these closely to ensure ongoing improvement. We will provide the coroner with our full response to the report in due course. We are committed to acting on the lessons learned.”