Fatal Delays in Sepsis Care: Bethan James’s Death Was Preventable, Inquest Finds

The daughter of former England and Glamorgan cricketer Steve James died after a series of critical delays in her medical care, an inquest has found — with the coroner concluding that she would not have died had she been treated sooner.

Bethan James, a 21-year-old journalism student from Cardiff, died on 08 February 2020, just hours after being admitted to the University Hospital of Wales.

A post-mortem found she died from sepsis and pneumonia, with Crohn’s disease listed as a contributory factor.

What Is Sepsis?

Sepsis is not just an infection. It’s the body’s overwhelming and life-threatening response to an infection that can lead to tissue damage, organ failure, and death. It is so serious that international health leaders launched the Surviving Sepsis Campaign, aimed at educating healthcare professionals about early recognition and treatment.

Prompt treatment is essential. Every hour that sepsis goes untreated increases the risk of death. That’s why front-line healthcare workers—doctors, physician assistants, nurse practitioners, and nurses—must be trained to identify its early signs and act swiftly.

Common Signs and Symptoms of Sepsis

While anyone can develop sepsis, it’s most dangerous for older adults, people with chronic illnesses, and those with weakened immune systems. Signs to watch for include:

• Temperature changes – chills, fever, clammy or sweaty skin
• Breathing difficulties – rapid or laboured breathing
• Mental confusion – sudden disorientation or confusion
• Intense pain or discomfort – often described as the worst pain ever
• Heart abnormalities – elevated heart rate or dangerously low blood pressure

Standard Treatment for Sepsis

Sepsis is typically treated in stages: sepsis, severe sepsis, and septic shock. The earlier treatment begins, the better the chances of survival. Common treatment includes:

• IV antibiotics to treat the underlying infection
• IV fluids to maintain blood pressure and organ perfusion
• Medications to stabilise blood pressure and reduce inflammation
• Insulin and pain relief as supportive measures

Early Intervention is Crucial

Bethan’s rapid deterioration shocked medical staff, with Dr Duncan Thomas — the emergency physician who treated her — telling South Wales Central Coroner’s Court he was “astounded” by how quickly her condition worsened. “The rate of Bethan’s deterioration was not something I had previously observed in someone of her age group,” he said, calling it an “extraordinarily atypical” case.

But expert witness Dr Chris Danbury sharply disagreed with that assessment. He told the inquest that, based on the evidence, her case was consistent with a young patient with partially treated pneumonia, and that aggressive, early intervention — particularly immediate admission to the resuscitation area — could have prevented her death.

A Catalogue of Missed Opportunities

The inquest, held in Pontypridd, examined a three-week period in which Ms James repeatedly sought medical help. After being diagnosed with Crohn’s disease in 2019, Bethan suffered ongoing gastrointestinal issues and, in late January 2020, she was diagnosed with community-acquired pneumonia. She struggled to complete her course of antibiotics due to severe side effects.

On 08 February 2020, she was admitted to University Hospital of Wales. However, the ambulance crew that transported her did not issue a pre-alert — a standard protocol for severely ill patients. This meant that she was not admitted directly to the emergency department’s resuscitation area, which is designated for the most critical cases.

Dr Thomas said this resulted in approximately a one-hour delay in checking her lactate levels — a key diagnostic marker in sepsis — and administering fluid resuscitation. Although he believed that the damage to her organs was already too extensive, Dr Danbury argued that the delay had a “huge impact,” and that earlier action could have prevented her cardiac arrest.

‘She Would Not Have Died’

Coroner Patricia Morgan found that “a number of delays” in Bethan’s care “more than minimally contributed” to her death, concluding that “on balance, she would not have died” had care been provided in a timely and appropriate manner.

Coroner Morgan was “more persuaded” by Dr Danbury’s testimony, stating that: “Had this direct admission to resus and prompter recognition and treatment occurred, then cardiac arrest would not have occurred when it did, which would have enabled more time for other specialities to become involved in Bethan’s care.”

She ruled that sepsis was the immediate cause of death, with pneumonia as the underlying condition and Crohn’s disease as a contributing factor.

Family Devastated, Call for Reform

Outside the courtroom, the James family expressed their heartbreak. Their barrister, Richard Booth KC, read a statement on their behalf:

“It is heartbreaking to know that with appropriate treatment, Bethan would not have died. At 21 and just finishing her journalism degree, our beautiful Bethan had a brilliant and full life ahead of her, but it was taken away by a catalogue of errors that could so easily have been avoided by better listening, understanding, recognition and actions by health care staff.”

The family has called on the Welsh government to adopt “Martha’s Rule” — a reform introduced in England following the death of 13-year-old Martha Mills in 2021. It gives patients and families the legal right to request a second opinion when concerned about a patient’s condition.

“We urge the Welsh government to implement Martha’s Rule across the NHS in Wales so that needless and tragic deaths like Bethan’s aren’t repeated,” the family said.

Government Response

In response, the Welsh government said that making sure the voices of patients and their families are heard is “paramount.”

It confirmed it is working with NHS organisations to establish a robust escalation process and implement a patient safety plan to help healthcare professionals identify and respond to signs of patient deterioration more effectively.

How can Irvings Law help you?

Sepsis can escalate quickly, but with proper diagnosis and timely treatment, it is often preventable.

If you or a loved one has been seriously injured due to delayed or substandard treatment of sepsis, you may be entitled to compensation for the harm caused.

lrvings Law are specialists in handling medical negligence claims and are committed to securing financial compensation for victims of medical negligence.

We act on a ‘No Win, No fee’ basis. If your claim is successful, the costs will be paid by the Defendant. If the claim is not successful, the costs will be written off and you do not have to pay anything.

Contact us today for a no obligation and confidential chat on 0151 475 1999 or info@irvingslaw.com to see how we can help you