Mr Yusuf Seyit · Prevention of Future Deaths report

I opened an inquest into the death of Mr Yusuf Seyit, (████████ and ████████), who died on 3rd July 2019 aged 72 years on 12th September 2019. The delay in holding the inquest was ascribed to the impact of the Covid pandemic.

The medical cause of death was: 1a Septicaemia 1b Urinary Tract Infection II Immunoglobulin G4 disease, Myelodysplastic syndrome, Diabetes Mellitus. The narrative conclusion was natural causes was contributed to by a delay in administering antibiotics in septic shock.

Mr Seyit suffered from multiple diseases which immunosuppressed his response to infection and had been in hospital since January. The family reported pain on passing urine on 30th June. He had an indwelling catheter and a urine infection was suspected on 1st July, when he had suprapubic tenderness as well as signs suggestive of a chest infection. The urine result was reported at 17.50 on 2nd July as highly resistant E coli, sensitive to Amikacin. At this time he was stable but there was an indicator of infection – the slightly elevated CRP of 23. He acutely deteriorated at 05.00 with septic shock and a medical review concluded at 06.25. He was prescribed three antibiotics (he had a chest infection as well) including Amikacin. It is not known when in the morning Amikacin was administered. He died at 20.00

1. He was known to be at high risk of fatal infection and had developed symptoms 2 days before death and definitive proof of infection by the late afternoon of 2nd July, but it was not clear whether there was a plan for antibiotic intervention and no treatment was begun that day.

2. When in septic shock in the early hours of 3rd, three antibiotics were prescribed and our initial death report indicated treatment had begun before he died. But the medical records available to the inquest did not confirm when Amikacin was actually administered. Evidence of a consultant physician was that it needed to be within an hour.