Timothy Alastair Mason · Prevention of Future Deaths report

On 15th August 2018 I commenced an investigation into the death of Timothy Alastair Mason, aged 21 years.

The conclusion of the inquest was that the medical cause of Timothy’s death was 1a. Meningococcal Septicaemia.

The narrative verdict was due to the failure to diagnose and treat Timothy at Tunbridge Wells Hospital and had he been correctly treated he probably would not have died.

In addition, during the course of the investigation it was clear that Timothy had not been vaccinated with Men ACWY as his medical records confirmed. It appeared from the evidence that there were considerable concerns for the provision of the vaccination of people of Timothy’s age, in the way they were informed of the availability of the vaccine, the computer records of the way GP’s were informed and notified by NHS England and monitored and what steps are being taken to improve the system to ensure people are notified, advised and monitored to ensure they receive the vaccination in the future.

On the 16th March 2018 Timothy had been unwell for several days and had been seen by his GP. His symptoms worsened, and he attended Tunbridge Wells Hospital at 3.30 am. He was given fluid resuscitation and antibiotics. At 07.45 he was seen by ████████ and told he had a virus and was sent home. Timothy became worse and returned to the hospital on the same day at 15.15 where he was given treatment despite which he died at 21.46.

In addition, it was clear from the evidence from ████████ of the Saxonbury House Medical Group that Timothy had not received the Men ACWY vaccination and it was unclear whether he had been invited to have the vaccination, or had been and decided not to. There seems considerable doubt as to how GP surgeries arranged for the vaccination and the way NHS England provided the program for the doctors and monitored the notification of the vaccine to ensure anyone of Tim’s age would receive the vaccination..

(1) The reasons for the failure to correctly diagnose and treat Timothy on the 16th March 2018 at 03.30. What staff instructions were given to the doctors and nurses in the Emergency Department at the hospital for dealing with patients with symptoms suggestive of sepsis and what tests should have been carried out and why they were not done.

(2) Why was Timothy discharged home on the morning of the 16th March 2018 when he was clearly very unwell and tests had not been carried out.

(3) What steps have been taken by the Trust to avoid this situation happening again to another patient in the future.

(4) What training is being given to the doctors and nurses to avoid this situation in the future.

(5) How it happened that Timothy did not receive the Men ACWY vaccination and what systems are in place to ensure patients do receive the vaccination, how this is provided and monitored by NHS England and whether this is adequate or should be improved to avoid patients failing to receive the vaccine.
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