An amateur footballer who died from a flesh-eating virus could have been saved if paramedics had taken him to hospital, a coroner has said.
Luke Abrahams, 20, passed away from sepsis and necrotising fasciitis at Northampton General Hospital on January 23, 2023.
Surgical intervention a day before could have made ‘a difference’, assistant coroner Sophie Lomas told an inquest at The Guildhall.
However, she also could not conclude whether ‘earlier conveyance’ would have prevented Mr Abrahams’ death.
The East Midlands Ambulance Service said they were ‘deeply sorry’ that they missed an opportunity to take the 20-year-old to hospital.
Speaking after the four-day inquest, his brother Jake said his family ‘can never forgive the NHS for letting Luke down’.
Mr Abrahams had been complaining of a sore throat days before his death and saw his GP, who diagnosed him with tonsillitis and prescribed him antibiotics.
He later became immobile with severe leg pain after his condition deteriorated, and on January 20, an out-of-hours doctor misdiagnosed him with sciatica via a video consultation.
Luke Abrahams, 20, (Pictured with his mother Julie Needham) passed away from sepsis and necrotising fasciitis at Northampton General Hospital on January 23, 2023
The amateur footballer could have been saved if paramedics had taken him to hospital, an inquest heard
Just 12 hours later, his family dialled 999 as Luke was in severe pain – but ambulance crews decided he did not need to go to hospital despite high blood sugar levels and temperature.
Two days later, the railway engineer was rushed to hospital, saying he ‘could not take the pain any longer’ – and died the following day.
A post-mortem found he had suffered from septicaemia, Lemierre syndrome, a form of bacterial infection, and necrotising fasciitis – a flesh-eating disease.
The coroner found the amateur footballer had been affected by Lemierre’s syndrome, an extremely rare disease which is very challenging to diagnose.
Mr Abrahams’ parents believe mistakes made, including misdiagnosis in the beginning, could have led to their son’s death.
Because of the condition’s high mortality rate as well as the challenges with diagnosing the disease, it was not possible to conclude if earlier intervention would have saved Luke, Ms Lomas told the inquest.
The coroner recorded a narrative conclusion, finding that Mr Abraham’s had died after a cardiac arrest caused by septic shock.
Initially, the 20-year-old’s death was recorded as natural causes, and no inquest was opened.
Since, his parents Richard Abrahams and Julie Needham have fought for a formal probe to be opened as they believed a ‘catalogue of errors’ contributed to his death.
However, assistant coroner Sophie Lomas also could not conclude whether ‘earlier conveyance’ would have prevented Mr Abrahams’ death (Pictured: Luke with his father, Richard, mother Julie and his younger brother Jake)
The East Midlands Ambulance Service said they were ‘deeply sorry’ that they missed an opportunity to take the 20-year-old (Pictured with his brother, Jake) to hospital
The couple, from East Hunsbury, said GPs, A&E and 111 missed various opportunities to potentially save their son during his final week.
Susan Jevons, Head of Patient Safety at East Midlands Ambulance Service (EMAS), previously admitted that Luke should have been taken to hospital before his death.
‘Luke should have been transferred to hospital on the 20th, and he should not have been discharged at home,’ she said on the first day of the inquest.
When Luke’s condition failed to improve despite being on antibiotics, Luke and his mum contacted NHS 111 again.
EMAS paramedics arrived at 4pm that afternoon and found Luke in severe pain and unable to mobilise.
Ms Jevons said the crew focused on sciatica and failed to properly consider infection, despite multiple ‘red flags’, including a high temperature and blood sugar levels
These also included a pain score of nine out of 10, raised heart rate, dark-coloured urine and significantly high blood sugar levels.
Luke was not diabetic but recorded a blood sugar reading of 16, with 17 being the threshold for automatic referral to A&E, the inquest heard.
‘The blood sugar stood out the most for me. There was no reason his blood sugar levels should have been that high,’ Ms Jevons added.
Mr Abrahams had been complaining of a sore throat days before his death and saw his GP, who diagnosed him with tonsillitis and prescribed him antibiotics
Ms Jevons said a low warning score should not be used alone to judge how ill a patient is, but also what the patient is saying and their appearance.
A pain score of nine places a patient in the ‘red’ category, meaning they should be taken to hospital.
Meanwhile, Luke was recorded as ‘amber’, and the score was not challenged.
Ms Jevons said: ‘There wasn’t enough evidence to say he just had sciatica.’
She said the case led to additional training, including refresher training on sepsis, Lemierre’s syndrome and necrotising fasciitis.
Giving evidence, the out-of-hours doctor who wrongly diagnosed sciatica following a video consultation said he did not notice any ‘red flag’ symptoms.
Dr Olalowo Olaitan, who appeared via Zoom from Canada, was working as an out-of-hours GP for DHU Healthcare on behalf of NHS 111 at the time.
He said a video assessment was carried out as Luke was in too much pain to attend the hospital in person and was struggling to get down the stairs at home.
He said the video call was used to assess Luke’s level of consciousness, communication and to look for red flag symptoms such as rashes or skin changes.
He said there were no visible signs of redness, rash or discolouration to suggest a serious infection like necrotising fasciitis, which Luke later died from.
‘There was just pain in the back, buttock and leg,’ Dr Olaitan said, while explaining he believed Luke had sciatica, so he offered stronger pain relief and prescribed naproxen.
Asked why the throat infection was not explored further, he replied: ‘Based on the fact Luke said it was getting better and he was on antibiotics, I didn’t explore that further.’
He told the inquest his working diagnosis was sciatica alongside a throat infection and said he did not consider a connection between the two at the time.
Dr Olaitan also told the court he was unaware Luke had contacted NHS 111 several times in the days before, or that he had attended hospital earlier that week.
He added: ‘Ideally, I always want to see my patients face to face.’
Following today’s conclusion on the third anniversary of Luke’s death, Elizabeth Malaikai, a solicitor representing his family, said the inquest had been ‘immensely difficult’ for them.
She detailed how the family had sat and listened to various sectors of the NHS and ambulance service detail what they should have offered the ‘much-loved son and brother’ help.
‘They’ve also heard apologies for the poor way they were supported, as Luke was fighting for his life in hospital,’ she told the BBC.
‘He was assessed by health professionals on five separate occasions before finally being admitted to hospital.’
The solicitor said that even though answers and apologies had been given during the inquest, accountability had not emerged.
Radd Seiger, the family’s acting spokesperson, said the EMEA should have taken Luke to hospital up to two days before his death.
‘We believe that there was a good chance that Luke could have survived had that happened,’ he said, while confirming the family would launch a civil suit against the ambulance service.
Keeley Sheldon, director of quality at EMAS, said: ‘I am deeply sorry that we missed the opportunity to take Luke to hospital on 20 January 2023.
‘We failed to provide the level of care he deserved.
‘My condolences are with Luke’s family and all who loved him, particularly today on the third anniversary of his tragic death.’
An investigation was carried out that year and the trust took actions, Sheldon explained, and she said her team would review the coroner’s findings to ‘identify further steps we can take to prevent this happening again’.
NHS Northamptonshire Integrated Care Board said it was ‘deeply sorry’ to the family following Luke’s death.
He later became immobile with severe leg pain after his condition deteriorated, and on January 20, an out-of-hours doctor misdiagnosed him with sciatica via a video consultation
Maria Laffan, chief nursing officer, said: ‘[We] will work with all our partners and involved organisations to continue to take all steps necessary across our whole system to improve in those areas identified.’
Following the coroner’s findings, Jake, Luke Abrahams’ brother told Sky News: ‘We have had to fight every minute of every day since then to get answers.
‘We even had to fight for this inquest, with the hospital having told the coroner that Luke died of natural causes.’
He added that the family could ‘never forgive the NHS’ for letting his brother down, while detailing that the pain ‘has not eased’ over the last three years.
‘Time is not a healer… Luke should still be alive, living his life, playing football, laughing with his friends, planning his future.
‘Instead, we are left with an absence that never goes away.’
