A young man died after he was told to leave A&E due to overcrowding – despite having red flags for sepsis, an inquest has heard.
Garth Pretorious, 36, underwent a routine fertility procedure for Klinefelter syndrome, a genetic condition that affects sperm production, on December 19, 2024.
The procedure – which involved extracting sperm directly from testicular tissue – was successful but a week later he fell ill and attended the out of hours service at Goole Urgent Treatment Centre in Hull.
Mr Pretorious was triaged and found to have ‘red flag’ signs for sepsis – which typically presents as confusion or slurred speech, muscle pain, difficulty breathing and pale skin, lips or tongue.
Despite the reaction being life-threatening due to the risk of organ failure, Mr Pretorious was redirected to A&E at Hull Royal Infirmary.
Fatally, when he arrived at the emergency department the ‘Sepsis 6 pathway’ was not implemented, Professor Paul Marks, the senior coroner on the case, told the inquest.
This pathway consists of three tests and three treatments to restore blood flow and oxygen to vital organs as quickly as possible, and should be triggered within an hour of a sepsis diagnosis.
But due to ‘confusion over the arrival of an impending emergency at Hull Royal Infirmary,’ Pretorious, along with 15 other patients, were ‘effectively told to leave the department’ the inquest heard.
Garth Pretorious was redirected to the Emergency Department at Hull Royal Infirmary after he was diagnosed with life-threatening sepsis
‘As a result of this, there was a delay of approximately 24 hours in commencing appropriate treatment for sepsis which is a time sensitive condition,’ Prof Marks said.
‘This delay more than minimally, negligibly or trivially contributed to Garth’s death at Castle Hill Hospital on January 3, 2025.’
Sepsis most commonly develops from a bacterial infection and develops very quickly.
It occurs when the body’s immune system goes into overdrive, setting off a series of serious reactions that can lead to organ failure.
For every hour of delayed treatment, the risk of death increases by up to eight per cent.
But the life-threatening reaction can be extremely difficult to recognise, especially in babies and young children.
In this age group, symptoms include difficulty breathing or breathing very fast, seizures, a high or low temperature, being sleepier than normal or difficult to wake, and a change in urinary habits.
Babies and children under five may also not be interested in feeding or they may be repetitively sick, according to the NHS.
Adults may also present with slurred speech, uncontrollable shivering and a low temperature. But a child or adults with sepsis might not have every symptom, according to experts.
Anyone who thinks they may have sepsis requires immediate medical attention, and should receive antibiotics within an hour of arriving at hospital.
NHS figures show there were more than 118,000 emergency admissions for sepsis in 2024-25.
The UK Sepsis Trust estimates that ‘thousands’ of the 48,000 annual deaths from sepsis-related illnesses each year are preventable.
It has since been discovered that two different triage systems – which are used to identify patients in need of urgent medical attention – were being used when Mr Pretorious arrived at the emergency department.
Experts believe this played a significant role in Mr Pretorious’ death, warning that more deaths will occur ‘unless action is taken’.
One of these systems is known as the Manchester System, which Professor Marks says requires training the hospital did not have the resources to carry out appropriately.
After the report was made public, doctors labelled the findings ‘grim’ and ‘awful’ on social media, concluding that Mr Pretorious ‘deserves both justice and privacy’.
It comes as the NHS plans to give patients wearable sensors that detect the symptoms of sepsis in a bid to cut sepsis deaths by a quarter by 2035.
