Coroner investigating death criticises ED for using two triage systems

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By Daniel Pye

Concerns that an emergency department simultaneously used two triage systems due to a lack of resources for training have been raised by a coroner who investigated the death of a patient.

Garth Pretorius, 36, had a 24-hour delay to treatment for sepsis after “effectively being sent home” from Hull Royal Infirmary, the coroner said.

This wait more than minimally contributed to his death on 3 January, 2025, Professor Paul Marks, senior coroner for Hull, concluded.

In his prevention of future deaths report, Marks said he was concerned that some staff at the ED used the validated Manchester Triage System, while others used a different approach and “continue to do so”.

The inquest heard evidence from an independent expert that it was “unacceptable” to have two triage systems operating simultaneously.

The coroner was told this was because the Manchester system requires training, but “there do not appear to be sufficient resources” for it to be adopted universally at Hull Royal Infirmary.