David James FENN · Prevention of Future Deaths report

On 18 February 2025 I commenced an investigation into the death of David James FENN aged 68. The investigation concluded at the end of the inquest on 25 February 2026. The conclusion of the inquest was Natural Causes and it found that:
"On 12th February 2025 at Colchester General Hospital, Turner Road, Colchester, Essex, David James FENN died of multi-organ failure secondary to septicaemia which was a consequence of septic arthritis of the left knee (against a background of several other significant contributing comorbidities)."

Hospital referral

David Fenn, a 68 years old gentleman, was admitted into A&E Dept of Colchester General Hospital on 1st February 2025 with suspected sepsis / septic left knee arthritis. He had a history of previous Total Knee Replacement followed by multiple revision surgeries over many years. His past medical history included Liver Cirrhosis with Portal Hypertension, Advanced Kidney disease Stage, and Atrial Fibrillation (on Edoxaban). Following urgent surgery on 2nd Feb he was admitted to the ICU where he required multiorgan support and antibiotics for severe sepsis but he progressively deteriorated. After ongoing family discussions about his severe condition, he was pallated due to progressive multiorgan failure and failure to respond to treatment.
Sadly he died on 12th February 2025 at 10.23 hrs.
The Medical Cause of Death was found to be :
1 a) Multi-Organ Failure..
1 b) Septicaemia
1 c) Septic Arthritis Left Knee
2) Liver Cirrhosis, Portal Hypertension, Advanced Chronic Kidney Disease

The Court heard that Mr Fenn had in fact attended Colchester General Hospital a few days earlier with similar symptoms on 28th January 2025 but after several hours he was discharged home. It was accepted by the Hospital that with hindsight he should not have been discharged home and that instead the Sepsis 6 pathway should have been followed and that he should also have had urgent knee surgery to address the source of the sepsis. The Court ruled that whilst it could not be satisfied on the balance of probability that he would
have survived had he not been discharged on the 28th January, it did observe that he could possibly have survived.

On the 28th January 2025:
1) Signs of sepsis where not appropriately recognised and the Sepsis 6 Pathway was not followed.
2) An early Consultant Review was not sought.
3) The later attempt to seek the Consultant's views was hampered by the use of a mobile phone which had poor signal in the operating theatre and crucial information was not fully imparted/understood.
4) The junior doctor did not feel able to challenge the view of the Consultant to discharge nor did they seek to reapproach them with fuller information.
5) An alternative Consultant's opinion was not sought.
6) The Multi Disciplinary Team meeting the following morning did not discuss Mr Fenn's case when it should have.