Investigation and inquest
On 20th of November 2015 I commenced an investigation into the death of Hunter Jack Macmillan. The investigation concluded at the end of the inquest on 5th September 2016 with a narrative.
Circumstances of the death
Hunter Jack Macmillan was booked into the Urgent Care Centre at West Middlesex Hospital before, as a result of his condition, being taken to the Emergency Department at West Middlesex Hospital. He was not triaged in the Emergency Department for over 45 minutes by which time his condition had deteriorated.
Coroner’s concerns
Staffing levels in the Emergency Department were not sufficient to be able to follow national (currently NICE Guideline, Sepsis:recognition, diagnosis and early management) or any local policy on treating suspected sepsis.