Missed opportunity for earlier transfer to hospital: Leila Benyounes represents the Family of 20 year old footballer who died after developing sepsis and necrotising fasciitis
Leila Benyounes represented the Family of Luke Abrahams in an inquest at Northampton Coroners Court.
Luke, a much loved son and brother and an amateur footballer, developed a sore throat on 15 January 2023. He was diagnosed with tonsilitis by a nurse practitioner, the first of multiple healthcare professionals that he saw over the week before his death, and prescribed antibiotics. Luke developed severe leg pain and became immobile and was diagnosed with sciatica by an out of hours GP. Due to increasing pain and a temperature on 20 January 2023 three days before his death, Luke’s family contacted 999 for an ambulance and the attending paramedic crew assessed Luke before discharging him instead of transferring him to hospital. Following further 999 calls on 22 January 2023, Luke was taken to hospital by ambulance where he underwent emergency surgical debridement due to necrotising fasciitis and a left leg amputation. Sadly, at that stage Luke was in septic shock, and he suffered a cardiac arrest following surgery, from which he could not be resuscitated. Luke died on 23 January 2023 at Northampton General Hospital.
After a post-mortem examination, Luke’s death was initially recorded as natural causes. Following submissions to the Coroner on behalf of Luke’s Family, an inquest was opened, and two pre-inquest review hearings took place. In a four day inquest which concluded on 23 January 2026, the third anniversary of Luke’s death, Assistant Coroner Sophie Lomas gave a narrative conclusion finding that Luke died due to a rare condition called Lemierre Syndrome which presented as a sore throat and over the course of a week progressed to a septic emboli which travelled through his blood stream and developed into necrotising fasciitis. At the point of diagnosis, Luke was in septic shock, underwent emergency surgery but died following a cardiac arret due to septic shock.
At the first ambulance attendance, Luke had severe pain in his leg, had been immobile for four days, had a recorded pain score of nine out of ten, and an elevated temperature and elevated blood glucose reading.
The ambulance service admitted at the inquest that Luke should have been transferred to hospital on 20 January 2023 and the Crew did not adhere to Trust guidelines and policies. The Coroner accepted the Family’s submission that this constituted a gross failure to provide basic medical care by the ambulance service.
Evidence confirmed that the crucial period of time for debridement surgery for necrotising fasciitis was 24 hours earlier to improve survival rate, and therefore in Luke’s case there was at least a 48 hour period of opportunity for earlier intervention had the first ambulance transported Luke to hospital. The Coroner found that it is likely at that time that Luke’s blood results would have been abnormal prompting further investigations, he would have undergone earlier surgery, and on the available evidence it is possible that Luke would have survived.
The Coroner issued a Regulation 28 Prevention of Future Deaths Report as the NHS guidance described Necrotising Fasciitis as a rare and life threatening infection if a wound gets infected, and the evidence at Luke’s inquest indicated that the information in the NHS guidance is inaccurate.
Ms Benyounes was instructed by Elizabeth Maliakal at Hudgell Solicitors.
Links to press articles:
https://www.bbc.co.uk/news/articles/c4g04e96eyxo
https://www.bbc.co.uk/news/articles/c4gl42dydypo
https://www.telegraph.co.uk/news/2026/01/21/patient-died-flesh-eating-disease-mistaken-tonsillitis
Leila Benyounes is Head of the Inquests Team at Parklane Plowden Chambers and is ranked by Legal 500 and Chambers and Partners for Inquests and Inquiries and Clinical Negligence. Leila is appointed as an Assistant Coroner in two coronial areas and Leila regularly represents interested persons in a wide range of inquests including Article 2 jury inquests and complex medical matters. She has a special interest in obstetric, birth injury and fatal cases providing representation at inquest and in clinical negligence claims. She has been appointed to the Attorney General Regional Civil Panel Band A since 2010. Her full profile can be accessed here.
