A man undergoing treatment for testicular cancer died as a result of delays in administering antibiotics, an inquest heard. Michael Ramon Jervis was diagnosed with testicular cancer in May 2023 at the Royal Cornwall Hospital Truro (RCHT).
An inquest into his death held in Truro in October last year heard how the 69-year-old had been independent, fit and active, and the cancer was treatable with a plan for four cycles of chemotherapy. At the time, oncology specialists at Treliske told Mr Jervis and his family that the aim of the treatment was curative.
The hearing also heard how, at first, Mr Jervis, from Camborne, responded very well to the chemotherapy, and after three courses of the treatment, he was discharged home on July 9, 2023, with a plan to admit him for the fourth round of chemotherapy. The court heard how Mike was re-admitted to RCHT four days later after becoming unwell.
Bloods were taken on admission which revealed neutropenia, a condition which involves a significant weakening of the immune system and indicates a high risk of sepsis.
An acute oncology nurse specialist recorded on Mr Jervis’ notes that antibiotics should be administered should his temperature fall below 36 or rise above 37.5 – which is standard practice and consistent with the hospital’s policy and guidance.
However, Mr Jervis only received a course of antibiotics some 20 hours after it was noted that he needed the medication. Mr Jervis sadly died on July 16, 2023, from neutropenic sepsis, a recognised complication of chemotherapy treatment for testicular cancer.
Assistant coroner for Cornwall and the Isles of Scilly, Guy Davies, who carried out the inquest into Mr Jervis’ death, said the late administration of antibiotics contributed to his death and was akin to neglect.
In a prevention of future deaths report dated December 30, 2024, and sent to RCHT, Mr Davies said: “Michael Jervis died on July 16, 2023, at Royal Cornwall Hospital in Truro from neutropenic sepsis, a recognised complication of chemotherapy treatment for testicular cancer.”
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Mr Davies said processes at the hospital should be reviewed in a bid to prevent future deaths from happening. He said that repeated observations and National Early Warning Score (NEWS) which determines the degree of illness of a patient using six physiological findings and one observation, were taken by numerous staff members which indicated that treatment for sepsis should be triggered and that antibiotics were required but this did not happen.
In his report, he said there was an absence of a digital alert on the hospital software, which could have alerted staff to the need to implement sepsis six. A bundle of six measures are required when clinical indicators of sepsis are present, known as the ‘Sepsis Six’ bundle.
The inquest heard that of the six measures, antibiotics is the most important and should be administered within 60 minutes. But in the case of Mr Jervis, it took 20 hours for that first course of antibiotics to take place.
In his report, Mr Davies said: “There was a 20-hour delay in the administration of antibiotics from the point at which clinical observations repeatedly indicated that antibiotics were clearly required. This delay in the administration of antibiotics more than minimally contributed to his death.
“The conclusion as to the death is that Mr Jervis died from a recognised complication of necessary medical treatment contributed to by neglect.”
A spokesperson for RCHT said: “We are deeply sorry for the missed opportunities during Mr Jervis’ care and would again extend our sincere condolences to his widow and family. We could, and should, have acted sooner to administer antibiotics which could have prevented his death.
“In addition to the Inquest, a comprehensive review of Mr Jervis’ care has been carried out, and we are absolutely committed to ensuring meaningful change and learning arises from the failings in his care.”
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