Coroner warning after sepsis patient was sent home

A coroner has urged a hospital trust to take action after a patient with symptoms of sepsis was discharged days before his readmittance and death.

David Fenn, 68, had attended Colchester General Hospital on 28 January 2025 with suspected sepsis but was discharged home within hours.

In a prevention of future deaths report (PFDR), senior coroner Lincoln Brookes said Mr Fenn "would have survived" if a so-called Sepsis 6 pathway had been followed and urgent knee surgery "to address the source of the sepsis" had been carried out.

"In my opinion there is a risk that future deaths could occur unless action is taken," the coroner said.

The coroner conducted his investigation following an inquest into Mr Fenn's death on 25 February 2026.

He said Mr Fenn had been admitted to A&E at Colchester General on 1 February 2025 with suspected sepsis and septic left knee arthritis - days after his initial hospital discharge.

The patient had previously undergone knee replacement and revision surgeries over many years, he said.

But following urgent surgery on 2 February 2025, he was admitted to intensive care where his condition "progressively deteriorated".

He died of natural causes in hospital on 12 February at 10:23 GMT, the coroner concluded.

Mr Fenn had suffered multi-organ failure, septicaemia, septic arthritis left knee - as well as issues with his liver and kidneys.

The report revealed concerns that a consultant review had not been sought at Mr Fenn's first admittance to hospital.

It said a later attempt was hampered by the poor signal of a mobile phone in an operating theatre - and a junior doctor had not felt able to challenge the decision to discharge him.

However, the coroner added: "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 hospital must respond to the report within 56 days of it being published.

The East Suffolk and North Essex NHS Foundation Trust has been contacted for comment.

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