A CORONER has returned a narrative verdict at the inquest into the death of a Notts teenager from blood poisoning.
Greg Bear, 17, died six days after his mother had first raised concerns about him having a severe headache.
Doctors and paramedics both thought he had flu-like symptoms, but he died of septicaemia at King's Mill Hospital in Sutton-in-Ashfield on December 22, 2010.
An inquest into his death at Nottingham Coroner's Court heard today that a paramedic who saw Greg at his home in Huthwaite Road, Sutton-in-Ashfield, on December 19, 2010, had attempted to send an Electronic Patient Report Form (EPRF) to GPs stating he had a chest infection.
But that message failed to be picked up by GPs as the NHS e-mail system used by the paramedic wasn't yet set up at Willowbrook Medical Practice, in Sutton-in-Ashfield, where Greg was a patient.
Giving evidence at the inquest, Dr James Gray, medical director at EMAS, said: "When the EPRF was introduced we requested NHSnet e-mail addressed for every practice in the East Midlands.
"In this case the NHSnet e-mail address for Willowbrook was not provided until January 2011, so the EPRF was not sent to the GP practice."
Dr Gray added that EMAS had since tried to learn from the case.
He said: "Greg's death has been very important in recognising the issues of sepsis as an entity and allowing us to raise awareness, not just at EMAS but nationally, to try and get a better understanding of the condition and to try and avoid future preventable deaths."
Dr Gray said a trial is now underway to provide paramedics with a checklist to follow in order to identify sepsis - or blood poisoning - as the initial symptoms can be similar to flu.
Sepsis was now also included on the service's educational programme, Dr Gray added.
He said: "The challenge we all always have in clinical practice is there is no black or white.
However, this case highlights people need to be aware of these grey areas."
Dr Amanda Sullivan, who was director of quality and governance at NHS Notts County Teaching PCT at the time of Greg's death, also gave evidence earlier.
She told the inquest she had led a review into the case and that staff had since received bulletins - including on their pay slips - which made them aware of how to spot the signs of sepsis.
When asked what effect Greg's death had on staff, Dr Sullivan said: "It's had an absolutely enormous effect on everybody involved."
She added: "This investigation was unusual in that we normally understand what the root causes are and make recommendations. But one of the findings (in Greg's case) was that for practitioners and paramedics sepsis was something they rarely came across."
Dr Sullivan said the trust is intending to reissue a warning it sent to GPs after Greg's death ahead of this coming winter's flu season.
She also called for national guidelines to be established to help GPs diagnose sepsis.
Notts deputy coroner Heidi Connor returned a narrative verdict on the case.
