Inquest into the death of Ben James Witham

17y · Male·Multi-organ failure with terminal fungal sepsis (Aspergillus) on a background of acute lymphoblastic leukaemia; gastric perforation was a contributing cause

Ben Witham, a 17-year-old with acute lymphoblastic leukaemia, died from multi-organ failure with terminal fungal sepsis. The critical issue identified was a substantial delay in investigating acute severe abdominal pain on 13 May 2011. Despite classic peritoneal signs noted at 9:30 pm (generalised tenderness, guarding, rebound tenderness), no imaging or surgical review occurred until 14 May, resulting in approximately 17 hours before laparotomy for gastric perforation. The consultant oncologist's assessment relied on a junior doctor's description rather than direct examination; further investigations including overnight x-rays and scans were available but not ordered. This delay allowed peritonitis and bacterial infection to develop, contributing significantly to death. The coroner found the standard of care during this period inadequate. An initial positive arsenic test result proved to be contamination/error; no public health risk existed.