Improvements can be made “up and down the country” as a result of the death of the son of a senior doctor, a coroner has said.
William Hewes died aged 22 at Homerton University Hospital in January 2023 within 24 hours of being admitted after his meningitis, caused by a meningococcal infection, developed into sepsis.
The 6ft 6in young man, who was studying history and politics at university, was said to have been fit and healthy before the infection.
Last month, the inquest at Bow Coroner’s Court heard that medical staff failed to administer antibiotics swiftly to Mr Hewes, and failed to do so within an hour of his arrival at hospital as per national guidelines.
Consultant paediatrician Deborah Burns, Mr Hewes’ mother, was a doctor at the same east London hospital for more than 20 years.
William Hewes (right) with his three siblings (Family handout/PA)
The inquest previously heard extracts from Dr Burns’ statement in which she expressed her belief that her son was “left unmonitored and untreated in resus for far too long” and that his care “was no better on the ICU until it was too late”.
On Wednesday, coroner Mary Hassell said that when she gives her conclusion, one element she will “certainly write about” is that “the lessons learned must be shared and must be shared at a national level”.
She said: “This isn’t the first time that I have heard an inquest where a great deal of the investigation has been driven by the family and I am sure it won’t be the last.
“Nothing will bring William back but it seems to me that others may be saved as a result of the work done following his death.”
The coroner said Martha Mills’ parents sat before her “in a very similar situation” and as a result their campaign, which gives patients and their loved ones the right to a second medical opinion, is being introduced nationally.
She added: “It seems to me that improvements can be made up and down the country as a result of William’s death.”
Earlier on Wednesday, Dr Claire Charley, emergency medicine consultant and clinical lead at Homerton University Hospital, said she was not aware of Dr Burns’ level of concern after her son died, the inquest heard.
Dr Charley said she attended a meeting in March 2023 in which they discussed the timeline of the events and she said “we recognised we hadn’t delivered gold standard perfect care”.
She said at the time she was not aware of the level of concern from Mr Hewes’ mother.
Dr Charley then told the court about a number of changes that have been made since the incident.
Speaking to Mr Hewes’ family, Dr Charley broke down in tears as she said: “I would like to personally tell you how profoundly sorry I am that we couldn’t save William that day, but I hope I have been able to demonstrate to you some of the things that we have done both at trust and departmental level to demonstrate to you that we have stopped to listen and we will learn.”
Put to her by Neil Sheldon KC, for the family, that during a meeting in March 2023 she and another doctor agreed an external review should be undertaken if Mr Hewes’ family feel it was required, but nobody asked the family, and asked whose fault it is, Dr Charley said “the trust’s”.
Bow Coroner’s Court previously heard Mr Hewes arrived at the hospital at 12.06am, and was quickly admitted to the hospital’s resuscitation area – “resus” – before arriving at the intensive care unit (ICU) around 4am.
Dr Ron Daniels, founder and chief executive of the UK Sepsis Trust, previously told the court he believed Mr Hewes was likely to have survived if he had received prompt care, and said it is “perfectly possible” for non-specialist medical staff to deliver the necessary treatment.
Earlier on Wednesday, former NHS consultant in intensive care Professor Patrick Nee, who said he was instructed by the hospital trust to assist with their review, gave evidence to the inquest and said it would be “a leap” to say Mr Hewes would have survived if his hospital care had been different.
Asked whether he agrees or disagrees with Dr Daniels’ evidence, Prof Nee said he agrees with the chronology and agreed that there are guidelines, and that “some of these criteria were not achieved”, including in terms of how the patient should have had antibiotics within the hour.
He also said Mr Hewes “became a non-responder” about two hours in and interventions could have started in ICU at about 3am – an hour earlier – if it was suggested at about 2am he needed ICU treatment.
Asked by the coroner if Mr Hewes would have had a better chance of survival if his care in hospital was different, Prof Nee said: “Potentially, yes,” adding: “It’s a leap … to say he would have survived.”
When he was asked whether Mr Hewes would have survived, or not survived, or if he does not know, if changes had been made as he would have wanted, at the time he wanted, Prof Nee said: “I think he probably would not have survived.”
The coroner will give her conclusion on March 27.