Published: 13:01, 18 October 2018
| Updated: 16:58, 18 October 2018
A coroner has concluded that a 21-year-old man's death could have prevented if he was treated by doctors who missed sepsis symptoms.
Tim Mason was sent home to die by staff at Tunbridge Wells Hospital in March and an inquest heard the NHS Trust admitted serious failings in the moments leading up to his death.
The trainee electrical engineer began to feel unwell on March 8 and days later told his mum he felt as though he was dying during a hospital visit.
VIDEO: Statement from Tim Mason's family
The inquest held at Archbishops Palace in Maidstone was told Tim was discharged by doctors with a wrongly diagnosed upper respiratory tract infection.
Within hours he was rushed to the emergency department by his parents after he collapsed.
Moments later he suffered a fatal cardiac arrest and could not be resuscitated.
Tim's mum Fiona read out a statement with her version of events and said her son was "vomiting more violently than anyone I had seen vomiting before".
VIDEO: Tunbridge Wells hospital apologises after death of 21-year old could have been avoided
Nurse Dr Joane Viera noted that he looked "very unwell".
However in the inquest she told of how staff "were not trained" to fill in a box that would alert to sepsis.
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This was despite Tim having symptoms of sepsis including a very high heart rate and temperature.
He was then seen hours later by junior Doctor Dr Max Bacon who was qualified for one year.
He ran blood tests on Tim but said the tests "falsely reassured" him and after advice from a senior doctor, Dr Bacon discharged Tim from hospital with a diagnosis of a upper respiratory tract infection. This had been wrongly put into hospital records as gastroenteritis.
Seven hours later Tim and his parents returned to hospital.
According to Fiona, Tim was "unable to walk or sit up in a chair". After being made to wait again, Tim was given emergency treatment including being put in an induced coma.
But it was too late.
Tim's organs failed and he died as a result of cardiac arrest shortly after 9.45pm on March 16.
In the inquest Dr Bacon admitted that he "wished we never discharged Tim" and "I wish I put him through the sepsis protocol".
Coroner Roger Hatch gave the cause of death as meningococcal septicaemia due to failure to diagnose and treat it at Tunbridge Wells Hospital.
He added that had it been treated he probably would not have died.
Speaking after the inquest, Fiona Mason said: "Tim was great company and fantastic fun to be with.
"There was always masses to talk about, sharing the daily trivia of life and the latest political turmoil.
"He was popular, with an enormous range of friends to which he was totally loyal.
"He had an unshakeable sense of right and wrong and was passionate about so many things; work, friends, family, animals and those less fortunate than him.
"Debating, arguing and righting wrongs were high on the agenda and family suppers could become very loud as a result.
"He was full of plans for his future, mapping out the next few years to include travelling with his brother and completing his apprenticeship.
"Our house used to be full of noise and laughter and life. It's now quiet and we're all struggling.
"Tim's life is precious and private for the family, but the events surrounding his death can be learnt from and if changes are made that result in lives being saved then that will be of some small comfort."
The family will now be working with the local hospital trust as it campaigns to prevent any similar deaths in the future.
Dr Peter Maskell, medical director of Maidstone and Tunbridge Wells NHS Trust, said: “We are truly sorry that we did not do everything that we could have clinically to help diagnose Timothy’s sepsis sooner, and take steps to treat this diagnosis.
"I would like to personally apologise unreservedly to Timothy’s family and friends for this tragedy.
“While no words can adequately address their loss, we will ensure that lessons are learnt by our doctors and nurses.
“We have carried out a full review of Timothy’s care and have taken a series of actions to address areas of our practice that fell short of the high standards we want for all of our patients.
"We constantly try to educate and raise awareness of sepsis, clearly a case like this would allow us to reinvigorate that training and education of all of our staff.
"When it comes to the tickbox, it is the responsibility of anyone who has that form to think sepsis and fill it in, but sometimes we don't do what we're meant to do and for that I'm terribly sorry.
"We're all human, and we heard at the coroner's court that maybe people didn't put two and two together, as a trust we must support the ongoing education and must recognise when a tragedy like this happens we must learn from it."
Three specific actions have been identified and acted upon as a direct consequence of what the trust learned from Tim’s death.
The Trust has since implemented a new protocol for senior review of all patients due to be discharged from A&E with abnormal observations.
It has also introduced a new protocol for review and escalation where there is a high volume fluid infusion in young adults, as this may indicate more severe illness.
The Trust is also re-emphasising to all clinicians, in learning and reflective teaching sessions based on Tim’s actual care experience, the importance of following the Trust’s Sepsis protocol.
Enable Law clinical negligence partner Paul Sankey said: "For Tim's family nothing can make up for his loss, but the acknowledgement of responsibility will go a small way to helping them move on.
"We should now be able to resolve a legal claim on behalf of the family."
More by this authorGuy Bell