Russells Hall Hospital failings contributed to sepsis death

Simon Smith pictured on holiday, three weeks before his hospital admission in July 2018

Neglect and hospital failings contributed to a man's death with sepsis, an inquest has found.

Simon Smith, 51, was admitted to Russells Hall Hospital in Dudley in July 2018 with a pain in his knee and died four months later from liver failure, caused by sepsis.

His inquest heard "multiple opportunities... to deliver life-saving treatment" were missed.

The hospital trust said it had since made "significant improvements".

Recording a narrative verdict, Black Country coroner Zafar Siddique said Mr Smith's death was avoidable and the hospital was guilty of gross failings and neglect, which contributed to the father-of-two's death.

However, he was satisfied Dudley Group NHS Trust had since made improvements.

Mr Smith died from liver failure as a result of sepsis, a post-mortem examination found

Despite displaying sepsis symptoms on 28 July, Mr Smith only got suitable drugs on 2 August, a report into his care previously found, by which point his condition was deteriorating.

"He was not seen again by a consultant on a ward round for four days," Prof Tim Nutbeam, who provided an expert report to the inquest, said.

"A four-day gap with ongoing deterioration is inexcusable. This is a terrible sequence of events with multiple opportunities to raise the alarm and deliver life-saving treatment."

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Mr Smith's wife of 25 years, Hayley, said his treatment was "terrible from beginning to end".

"You wouldn't treat an animal like that," she said following the conclusion of the inquest.

The Care Quality Commission had previously found patients with sepsis were not being managed appropriately by the hospital trust and by the time Mr Smith was admitted for the final time in October 2018 it was reporting weekly to the watchdog.

Diane Wake, chief executive of Dudley Group NHS Trust said the trust had made a number of improvements since Mr Smith's death, including introducing electronic sepsis monitoring to identify when a patient is deteriorating in a bid to "eradicate human error".