Man, 36, died from sepsis after routine procedure after A&E sent him home

A 36-year-old man died when a routine fertility procedure led to sepsis - after he was told to leave A&E due to overcrowding.

Garth Pretorius underwent a microdissection testicular sperm extraction in December 2024 to treat Klinefelter’s syndrome, which can lead to a low sperm count.

But just over a week later, he presented at Goole Urgent Treatment Centre with signs of infection.

Staff saw he had signs of sepsis and directed him to A&E at Hull Royal Infirmary.

But staff at the emergency department did not initiate the ‘Sepsis 6 pathway’ - which should have meant Mr Pretorius received oxygen, antibiotics and fluids soon after arrival.

Sepsis has a mortality rate of between 20 and 30 per cent, with survival rates heavily linked to how quickly the infection is identified and treated.

A coroner said he was then effectively told, along with 15 other patients, to leave the emergency department because of confusion over the arrival of another emergency.

This meant his treatment did not start for 24 hours, robbing medics of vital time to save his lfe.

Mr Pretorius died at Castle Hill Hospital in Cottingham near Hull on January 3 2025.

The delay “more than minimally, negligibly or trivially contributed to Garth’s death,” according to the inquest report.

Professor Paul Marks, Senior Coroner for Hull, has written to Hull Royal Infirmary to ask how they will prevent future deaths occurring amid concerns Mr Pretorius was not triaged correctly.

Two triage systems were being used in Hull on the day of Mr Pretorius presenting at A&E, the inquest heard, with this being described as “unacceptable.”

The Manchester system of triage, which is one of the most widely used across the world, was in use but another triage system was also being used, and continues to be used in the A&E, the inquest heard.

In response to the Prevention of Future Deaths report, a letter from the Humber Health Partnership read: “Firstly, we would like to express our sincere condolences to Mr Pretorius’s family for their loss. We recognise the importance of responding fully to the concerns raised.

“We note the Coroner’s concern that two different triage approaches are being used within the Emergency Department at Hull Royal Infirmary, and the associated risk to patient safety if there is inconsistency in the application of triage processes.

"The Trust is strengthening the consistent application of the Manchester Triage System through an expanded programme of training and assessment.

“Clinical Nurse Educators are actively delivering this programme to ensure that all staff undertaking triage are appropriately trained and competent in the use of the system. Progress is being made to ensure improved consistency and reliability in triage decision-making.

“Training in the Manchester Triage System is being delivered to 155 members of staff through a comprehensive three-stage programme comprising e-learning, a face-to-face workshop, and a final competency sign-off.”