Multiple failures by Royal Berkshire Hospital staff led to the death of a father-of-one, a coroner has ruled.

As previously reported, Michael Nye, from Crowthorne, had a heart attack and died within hours of arriving at Royal Berks Hospital on November 15, 2022. 

He turned up to A&E seriously unwell after presenting with symptoms of sepsis after contracting Strep A in a national outbreak that had killed at least two children. 

Today (Wednesday) assistant coroner Alison McCormick ruled his death was partly caused by hospital staff failing to spot signs of sepsis.

On the final day of an inquest into his death, Reading Coroner's Court heard that the coroner had written to the hospital calling for action to be taken to prevent further deaths. 

Recording her verdict, the coroner said: "I conclude that Michael died of natural causes but also that the actions of the staff at Royal Berkshire Hospital more than minimally contributed to his death."

The conclusion comes after three days of testimonials from medical professionals who determined that quicker treatment may have increased chances of survival and that doctors at Royal Berkshire Hospital missed signs of a soft tissue infection within the skin leading to advancing sepsis.

Michael and his partner Vin attended the A&E department of the Royal Berkshire Hospital on November 14 2022 after being advised by his GP due to flu-like symptoms, mottling on his skin and swelling to his neck.

Despite Michael being declared the ‘sickest patient on the ward’ it was determined that numerous elements contributed to an inadequate level of care to be given by medical staff.

When coming to the conclusion Coroner, Alison McCormack distinguished between "failure" and “gross failure” on the part of the hospital saying that there is no dividing line and that “clinical decisions were made to come to a working diagnosis”.

It was also said that the issues that occurred on the night amounted to a “failure but not a gross failure by hospital staff”.

According to evidence, some failings included failure to start antibiotics at an earlier time in the evening, failure to address the underlying cause of Michaels's illness and failure to come up with another diagnosis other than deep vein thrombosis.

A report will be written up for the Royal Berkshire Hospital Trust to identify these key failings and assign specific solutions to prevent further preventable deaths.

Alison McCormick said: “This inquest has given rise to concerns of risk of other deaths and I believe actions should be taken to reduce these risks.

“This includes training in intensive care on all levels, to ensure contemporaneous reporting from doctors and nurses, training and education of all clinical staff on atypical symptoms of sepsis particularly when there is a high lactate and a stop to a delay in blood tests and notification.”

Following the conclusion, the coroner thanked Sue, Vin, and the family who attended throughout the inquest for their courage, calm dignity and strength.

She added: “I would like to thank all representatives and consultants who took part in this open forum which uncovered evidence. The journey demonstrates an inquisition can help to explain issues that need to be raised.”