A HEREFORD factory worker died after Herefordshire's NHS trust failed to diagnose and treat his sepsis quickly enough, a Parliamentary and Health Service Ombudsman investigation has found.

Stephen Durkin died after suffering organ failure from sepsis, a life-threatening condition that occurs when the immune system overreacts to an infection, causing widespread inflammation that can damage the body’s own tissue.

His wife, Michelle, made a complaint to the ombudsman after she was left floored by his sudden death which she believed was avoidable.

Stephen was an otherwise healthy 56-year-old when he attended Wye Valley Trust A&E with chest pain in July 2017.

Hospital staff suspected he had a major blood vessel blockage and admitted him to a ward overnight.

The next morning his overall condition had worsened, but staff did not monitor him more closely, as national guidance advises, and he continued to deteriorate throughout the day.

The next day Stephen was admitted to intensive care and treated for sepsis but tragically died later that evening.

In the space of 48-hours his condition deteriorated rapidly but staff did not act quickly enough and the critical care team attended Stephen ten hours too late.

His wife Michelle arrived at the hospital to visit Stephen, only to find that he was critically ill and unresponsive. She was left devastated by his death and turned to the Ombudsman to look into what had happened with his care.


"My feelings regarding his death cannot be expressed fully in words. Stephen’s death was untimely and avoidable, he had so much to live for," Mrs Durkin said.

“I’m hoping that highlighting the mismanagement of Stephen’s treatment and care by Hereford hospital, which resulted in his death, can prevent anyone else from experiencing the same tragic journey myself and family have had to take.”

Ombudsman Rob Behrens said: “Stephen’s tragic death could so easily have been avoided. His case shows why early detection of sepsis, as set out in national guidelines, is crucial.

“Sadly, this is not the first time we have had to highlight this issue. There is clearly more the NHS needs to do. It is vital that NHS trusts ensure their staff are sepsis-aware to reduce the number of avoidable deaths from this life-threatening condition.”

David Mowbray, chief medical officer at Wye Valley NHS Trust, said: “We apologise unreservedly to Stephen’s wife and family for the delay in his diagnosis and treatment for sepsis.

“The trust swiftly improved training and monitoring to prevent deaths from sepsis wherever possible, and we continue to monitor and evaluate any sepsis-related deaths to ensure patients receive the highest standard of care”.


Following the investigation, and at the ombudsman’s request, the trust has provided extra training to its staff in sepsis management and advanced communication skills, and has introduced an electronic observations system that improves identification if a patient’s condition is deteriorating.

It explained that since doing so, it has seen a ‘considerable reduction’ in sepsis-related deaths, demonstrating how complaints can lead directly to service improvements in the NHS, and better outcomes for patients.