AN 81-year old man from Wrexham died of multi-organ failure after hospital staff failed to diagnose sepsis from an underlying UTI in a timely fashion, an inquest heard.

Philip Roy Parry of Llay, Wrexham, died on November 10, 2023, after being admitted to Wrexham Maelor Hospital by emergency ambulance, an inquest held in Ruthin on Tuesday, (September 18) was told.

Philip, known to his family as Bob, arrived at Wrexham Maelor Emergency Department (ED) at 11.45am on November 9, 2023. He had been ill at home for several days, experiencing symptoms of dehydration, vomiting and diarrhoea before collapse. 

Tests revealed Bob to have an elevated temperature, an abnormally fast heart rate and elevated white blood count. A diagnosis of acute injury liver and kidney failure was given. 

Bob also suffered several underlying historical conditions, including Chronic Myeloid Leukaemia, of which Bob was not made aware following a blood test in 2021.

The inquest heard that, upon review by Betsi Cadwaladr University Health Board, Bob's care ought to have been elevated. There was a 12-hour delay in Bob's case being reviewed by a doctor with opportunities to treat infection on the day of being admitted to hospital.

Further blood tests during the evening of November 9 found a clinician statement confirming Bob would not be treated with antibiotics at this time until his primary underlying condition had been determined through further investigation. Upon reflection, the clinician agreed that a broad spectrum antibiotic would have been a better course of action. At this stage, a UTI had not been diagnosed, despite the presence of dark and offensive smelling urine.

Eventually, Bob was given a course of antibiotics at approximately 7.20am on November 10, and was moved to a Resus Unit shortly before 8am where he was later joined by his family. His daughter described him at this time as "struggling to breathe, panicking and fighting for his life."

By the time a diagnosis of sepsis was given, he was already in multi-organ failure. Following a fast deterioration, Bob's death was verified at 12.25pm.

Head pathologist Dr Brian Rodgers confirmed the cause of death in his report as Multiple-Organ Failure as a consequence of Sepsis caused from a Urinary Tract Infection (UTI).

Elizabeth Jones, assistant coroner, gave a narrative conclusion, and said there was a poor recognition of sepsis and that failing to escalate Bob's care contributed to his passing.

The inquest heard: "The pressures faced by the Emergency Department cannot be overlooked due to the significant number of patients waiting to be admitted.

"There were a number of missed opportunities to provide Bob with timely treatment to treat sepsis. This was down to a combination of factors, primarily poor recognition of sepsis while under the care of the Emergency Department."

"The most inexcusable part", said the assistant coroner, "is that Bob was added to an electronic admissions system upon arriving in the ED, which the on call team were not made aware of through the system.

"Had he received earlier care, on the balance of probabilities, he would have survived."

A clear plan has been required from the health board moving forward, with quarterly updates requested by the coroner's court.