There was a “missed opportunity” to take an amateur footballer who died of sepsis and necrotising fasciitis – a rare flesh eating infection – to hospital, a coroner has ruled.
Sophie Lomas said it was not clear whether earlier treatment would have changed the outcome of his case, however.
Luke Abrahams, 20, from Northampton, returned home from a Sunday match complaining of a sore throat in January 2023.
His inquest at the town’s Guildhall heard how he was prescribed antibiotics for tonsillitis, but later that week he developed severe leg pain and an ambulance was called.
Paramedics diagnosed him with sciatica and did not take him to hospital, in spite of his pain level registering a “score” of nine out of 10, having a raised heart rate, dark-coloured urine, and high blood sugar levels.
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Giving evidence, Susan Jevons, head of patient safety at East Midlands Ambulance Service, said the crew had failed to properly consider infection, despite multiple “red flags”.
Luke’s condition continued to worsen, and two days later he was taken to hospital by ambulance.
A consultant in emergency medicine told the court Luke had been “catastrophically unwell” and had been experiencing multiple organ failure.
The court heard that a leg amputation was his only chance of survival, but he suffered a cardiac arrest after surgery and died on 23 January.
His death was initially recorded as “natural causes” but his parents Richard Abrahams and Julie Needham, requested an inquest. They said they wanted “justice and accountability” after the multiple contacts Luke had had with NHS bodies, including his GP, NHS 111, out of hours services, paramedics and doctors at Northampton General Hospital.
Ms Needham told the court she was “overall concerned about the lack of continuity of care over the seven day period before his death”.
In her written report, Ms Lomas said Luke had died of a rare condition called Lemierre syndrome, which is a severe bacterial infection.
It presented as a sore throat in his case, and “over the course of a week, progressed to a septic emboli which travelled through his blood stream to his soft tissue and muscles and developed into necrotising fasciitis”.
Keeley Sheldon, the director of quality at the East Midlands Ambulance Service Trust, said she was deeply sorry that the service missed the opportunity to take Luke to hospital on 20 January 2023.
She said: “We failed to provide the level of care he deserved. My condolences are with Luke’s family and all who loved him, particularly today on the third anniversary of his tragic death.
“An investigation was completed in 2023, including actions we took at that time. This was shared with Luke’s family, including our sincere apologies.
“We fully accept the findings of HM Coroner and will review them with careful consideration, to identify further steps we can take to prevent this happening again.”
Following the coroner’s report, a prevention of future deaths report will also be made to change the wording on the NHS website.
It currently says that the rare flesh-eating infection, necrotising fasciitis, is caused by an external wound, but this was not the case for Luke.
Dr Nicholas Price, an expert in infectious diseases, said Luke’s condition had started with bacteria getting into his tonsils, which caused infected blood clots to break off and disperse around his body.
He said that necrotising fasciitis would have progressed rapidly and “arguably hours make a difference, and days certainly do” in terms of potential outcomes for patients.
He said, that “even with no issues at all” with treatment, the condition only has a 15-20% mortality rate.
Luke’s mother described her son as a “happy, loving person” with a “big personality” who was a “joy to be around”.
She said he was an “inspirational young man” who had enjoyed creating a local men’s football team and she had had to get used to the idea of him “no longer coming home”.
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His father, Richard, said their hearts were “broken”.
“When mistakes are made in the NHS, the consequences can be fatal. Lives are lost. Families are destroyed. That cannot simply be dismissed as ‘one of those things’. There must be accountability,” he said.
“There must be justice for Luke. And there must be meaningful learning, so that awareness of rare but deadly conditions like Luke’s is improved and so that no other family has to endure the pain we now carry every day. We will not stop campaigning until we are sure those lessons are well and truly learned.”
