A coroner has criticised a hospital for its “neglect” that contributed to the avoidable death of a 39-year-old previously fit and healthy man.
Amir Halling died at Hillingdon hospital in London after multiple failings by staff, including an A&E doctor’s failure to realise that he had sepsis, the body’s toxic response to serious infection.
His family said they were “angry and devastated” at the hospital’s misdiagnosis and resulting delay in giving him antibiotics.
Halling, a trainee accountant, went to the A&E department at Hillingdon in the early hours of 16 May 2016, three days after banging his right leg on a door. His leg had swelled up and he felt increasingly unwell, an inquest into his death heard.
Despite his blood pressure having fallen to 70/40, the junior A&E doctor who examined him concluded that he may have a blood clot. Without seeking a more senior colleague’s opinion, she gave him fluids and sent him home with instructions to come back later that morning for a scan to identify any clot.
When the scan showed that he was suffering from an infection he was admitted to the acute medical unit (AMU) and began receiving antibiotics at 1.30pm. However, if staff had followed clinical guidelines that specify early use of antibiotics for sepsis, which kills 44,000 Britons a year, Halling would have started on the medication at 3.50am.
Although doctors and a senior nurse decided that he needed to be urgently moved to the intensive care unit they could not transfer him as all nine beds were full. He suffered a cardiac arrest on the AMU that evening and then a second, this time fatal, arrest as he finally arrived at the ICU.
Assistant coroner Catherine Wood, who heard the inquest at west London coroner’s court last week, concluded that Halling died as a result of sepsis due to cellulitis, “contributed to by neglect”.
The dead man’s father, Mohamed Halling, told the Evening Standard: “We are satisfied the word ‘neglect’ was used by the coroner. We think it is shameful that the hospital did not give antibiotics when we first went there.
“I did not expect to take my son home in a body bag. Hospitals need to be more aware of sepsis. He had a degree in computing and accounts; he has his life ahead of him. It’s a tragedy.”
The hospital admitted to multiple failings in the serious incident review it commissioned. However, Halling’s family sought independent medical advice, which uncovered other errors. It found that he would have survived if he had been treated more promptly.
Another more senior A&E doctor said she would have recognised and treated the sepsis if she had known about the patient’s unusually low blood pressure. Dr Arup Ghosh, a microbiologist and expert on antibiotics, said Halling should have had them as soon as he arrived at A&E. “That would have potentially changed the outcome,” he said.
Lynda Reynolds of Hugh James solicitors, the family’s lawyer, said: “What we’ve heard in court has highlighted multiple critical failings from Hillingdon hospital which resulted in Amir, a young, fit and healthy man, being let down by the NHS and needlessly losing his life through neglect on the part of the hospital.”
In a statement, the hospital acknowledged “failings in the care and treatment of Mr Halling. The trust has given a full apology to Mr Halling’s family and would like to reiterate that it is truly sorry for their loss and the distress caused to them.” The coroner noted that it had improved its recognition and treatment of sepsis since Halling died in 2016.
