An inquest heard Christopher Bradbury, from Trentham, Staffordshire, suffered a rare ‘Severe Invasive Soft Tissue Infection’, which can aggressively spread around the body
A coroner has issued a warning after a father died from a catastrophic infection eight days after suffering a tiny cut between two of his toes.
‘Much-loved’ Christopher Bradbury, 63, sustained what was a seemingly innocuous injury to his right foot, an inquest heard. But he had to be rushed to hospital as he became more and more unwell. Eight days after he got the cut, Mr Bradbury was dead.
The cut – which he suffered after falling at home – led to him experiencing severe multi-organ failure and severe septic shock. Mr Bradbury died on January 5 in 2024, having sustained the cut on December 28, 2023.
An inquest heard Mr Bradbury, from Trentham, near Stoke, Staffordshire, had suffered a rare ‘Severe Invasive Soft Tissue Infection’, which can aggressively spread around the body. Staffordshire Coroner Emma Serrano has now issued a warning over a ‘national lack of knowledge of Severe Invasive Soft Tissue Infections’.
Ms Serrano said Mr Bradbury could have been given an MRI scan sooner, which would have led to him being diagnosed sooner, but was not given one due to the lack of knowledge around the infections. She has now written a Prevention of Future Deaths report to NHS England and Royal Stoke University Hospital, where Mr Bradbury was treated and died.
An obituary for Mr Bradbury said he was ‘much-loved’ and will be ‘very fondly remembered’ by his family and friends. Married Mr Bradbury was a father of three and grandfather of three. Ms Serrano’s report said: “On December 28 2023 Christopher Granville Bradbury fell at his home address and sustained a cut between his two small toes on the right foot. He was admitted to the Royal Stoke University Hospital, Stoke-on-Trent, on January 2 2024. He had symptoms of diarrhoea and vomiting, and it was reported that he had collapsed.”
It continued: “He [had] a lesion on his little toe on his right foot and swelling to his right leg. On examination he was placed on the SEPSIS 6 pathway, and treated in accordance with this. He was examined by an Orthopaedic registrar who ordered an urgent MRI scan, to ascertain the cause of the swelling and the lesion. On January 4 2024, with no MRI scan being done, he received a Consultant review and a diagnosis of Invasive Soft Tissue Infection was made.
“He was too ill for a MRI scan and was taken directly to theatre for a below the knee amputation. After the surgery, he did not recover and passed away on January 5 2024. There was an opportunity for Mr Bradbury to be given a MRI scan, and if this had taken place, he would have been diagnosed earlier, and received the operative intervention at an earlier stage.
“It cannot be said that this would have made a difference to the outcome for Mr Bradbury. It was accepted in evidence that the issue giving rise to the delay in the MRI scan was down to a lack of knowledge of Severe Invasive Soft Tissue Infections, that are not (but are closely related to) necrotising fasciitis. It was accepted in evidence that there is a lack of national Guidelines on this.”
The inquest heard training is being delivered on the subject but “is not making significant inroads’ and “has not been effective at all”. Ms Serrano concluded “it is thought that this will happen again” and that the NHS must improve its lack of knowledge on Invasive Soft Tissue Infections and improve training.
NHS England and Royal Stoke University Hospital have until April 29 of this year to respond.
