Mum who watched son die of sepsis wants doctors to learn from family tragedy

William Hewes developed sepsis (Picture: PA)

A mum who rushed her severely ill son to hospital and watched him die hours later is urging other hospitals and doctors to learn from his death.

William Hewes, aged 22, died within 24 hours of being admitted to Homerton University Hospital in January 2023 after his bacterial meningitis infection developed into sepsis.

Medical staff failed to give him antibiotics within an hour of his arrival at hospital, going against national guidelines, due to a communication error.

William’s mum Deborah Burns had worked at that same hospital, in Hackney, east London, for more than 20 years as a consultant paediatrician. She says she raised the alarm eight times, and believes antibiotics were only given because of her intervention.

Dr Burns said on Thursday: ‘Getting to this point has been at huge personal cost. I have had no choice but to continue as it involves my integrity as a doctor. 

‘Throughout, I have had in mind my other children, their cousins, William’s many friends and all young people.

Deborah Burns says she raised the alarm about giving her son antibiotics eight times (Picture: Alfie Castang)

‘If it leads to learning and improvements in young people’s care, some good will have come from my family’s tragedy.’ 

The inquest into William’s death concluded at Bow coroner’s court this afternoon, where coroner Mary Hassell recorded his cause of death was ‘natural’.

Recording a narrative conclusion of the inquest, she said: ‘When he was admitted to hospital, William’s life threatening condition was recognised, but he didn’t receive immediate antibiotics, repeated fluid, or reassessment of his blood pressure and heart rate with the urgency that he should have.

‘He was already very unwell when he arrived, so it is unclear whether if he had been administered all treatment promptly, he would have survived.’

The night of William’s death

William arrived at the hospital just after midnight on January 21, 2023, and was quickly admitted to the hospital’s resuscitation area before arriving at the intensive care unit around 4am.

Studying history and politics and university, the 6ft 6in sporty student was described as fit and healthy before developing meningitis caused by a meningococcal infection.

Antibiotics were not administered to William as soon as possible and within an hour of his arrival, as per national guidelines, despite Dr Burns repeatedly raising the alarm.

William Hewes was just 22 when he died (Picture: Family Handouts/PA Wire)

He received antibiotics at about 1.25am – but Dr Rebecca McMillan, the emergency medicine registrar that night, had expected them to be given within 10 minutes of her instructing nurses to do so at 12.42am.

Nurse Marianela Balatico said she had not been told which antibiotics to give and concentrated on relieving William’s symptoms, adding: ‘The antibiotics slipped my mind.’

Throughout her son’s stay in resus and ICU, Dr Burns repeatedly asked hospital staff whether William had been given the antibiotics, telling them he needed them urgently.

The coroner concluded that this was an error of communication, and in a case where one member of medical staff told Dr Burns her son had been given antibiotics when he hadn’t, Ms Hassell concluded ‘she hadn’t listened properly to the question, I don’t think she intended to mislead’.

William ‘became a non-responder’ about two hours after being admitted, and Professor Nee suggested he could have been moved to ICU about an hour earlier than he was.

The amount of fluids given while he was in the resus room was ‘adequate or possibly excessive’, Professor Nee said, after being asked if he should have been given more earlier.

He died at 2.22pm on the same day.

Dr Ron Daniels, founder and chief executive of the UK Sepsis Trust, previously said he believed William could have survived if he’d received prompt care – something Professor Patrick Nee, former NHS consultant in intensive care, said was ‘a leap’.

However Ms Hassell concluded that she wasn’t convinced by either Dr Daniels or Professor Nee’s conclusions, saying: ‘I’m not convinced, even on the balance of probabilities, that the state of medical knowledge is such that we know the answer as to whether William would have survived had he received earlier treatment.’

Improvements could be made ‘up and down the country’

William (right) with his three older siblings (Picture: Family Handouts/PA Wire)

Earlier during the inquest, coroner Ms Hassell said other lives could be saved as a result of work done and changes made following William’s death, thanks to investigation work by his family.

She said: ‘It seems to me that improvements can be made up and down the country as a result of William’s death.

‘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.’

Speaking after the inquest Deborah Nadel, solicitor from Fieldfisher which represented the family, said: ‘We acknowledge and appreciate the coroner’s conclusion. The family are devastated to have lost William in these circumstances.

‘Unless errors like those identified during the inquest are discussed and acknowledged, lessons are not learnt and nothing changes.

William was a ‘fit and healthy’ young man (Picture: Family handout)

‘What has been clear throughout this hearing is that recognising and treating sepsis efficiently must be a priority so that more people don’t die.  

‘We will continue to investigate whether the errors clearly identified during the inquest did cause or make a material contribution to William’s death. Advice from Dr Daniels, Head of UK Sepsis Trust, is that they did.’

Homerton Hospital previously said the trust has taken ‘appropriate steps’ since William’s death to continue to reinforce awareness of suspected sepsis in patients attending A&E.

Homerton Healthcare NHS Foundation Trust said in a statement on Thursday: ‘The loss of William Hewes was devastating to his family and deeply touched everyone involved in his care.

‘We extend our deepest condolences to William’s mother, Dr Deborah Burns, a much admired and respected consultant paediatrician in our team at Homerton, and all of William’s family.

‘As the inquest has heard, William’s case was thoroughly reviewed by our team and by independent experts.

‘They found there were aspects of his care that could have been done differently, from which we have learned and made changes and improvements.

‘A full action plan was drawn up following the investigation into William’s death and several improvements have been made relating to how clinical staff manage suspected sepsis cases in our emergency department.

‘We will take on board what the coroner has said in relation to the actions we have taken and will be sharing these nationally with our NHS colleagues.  

‘We know that the impact of William’s death on his mother was compounded by it happening in the hospital where she works.

‘We have reflected on this rare situation, where a member of our staff is deeply impacted by the care provided to a family member.

‘Deborah has told us that our policies and processes for this situation are inadequate and detached and we are determined to learn from her experience.

‘This work will ensure a more personal response for staff members or members of their family who are patients here.

‘Our thoughts remain with Deborah and her family during this incredibly difficult time.’

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