Jem Abbott, a healthy 37-year-old, had gone into hospital for a vasectomy, the male sterilisation operation performed on more than 100,000 men every year in Britain.
The operation is routine, yet a little over a week later Jem was dead, the victim of septicaemia.
This vicious bacterial infection of the blood claims 37,000 lives a year, yet has been largely side-tracked as public attention focuses on the newer problem of superbugs - which kill 5,300.
In fact, septicaemia is a leading cause of death, after heart disease and cancer, and claims more lives than breast and bowel cancer combined.
It occurs when an infection in the blood stream causes the body's immune system to go haywire and start attacking the body it is meant to protect.
Among its victims are Superman actor Christopher Reeve, former Bee Gee Maurice Gibb and Pope John Paul II.
Devoted: Jem and Karen before he fell victim to septicaemia
Yet despite the number of lives it claims, its symptoms are often unrecognised by doctors and nurses. As a result the window for effective treatment is missed, with fatal consequences.
Now hospital specialists have launched a campaign to educate medical staff and raise public awareness of the condition - they say that prompt recognition and treatment for all septicaemia cases could halve the death rate at a stroke, saving thousands of lives.
Jem's widow Karen has joined this campaign. Almost four years after his death, and left alone to bring up their two children, Emily, now 15, and Thomas, 12, she remains shattered by the loss.
She says she would do anything to prevent people going through the trauma experienced by her family.
"We had completed our family, we were totally happy," she said.
"For Jem a vasectomy was the right thing to do."
He underwent the operation on a Friday. Doctors advised a couple of days' rest, but said Jem could return to work after the weekend.
"He was told it was a quick, completely routine procedure, and that there might be a bit of pain and swelling but nothing he couldn't handle," Karen said.
Indeed Jem, who was a director of a transport firm in Sutton Coldfield, had returned to work that Monday, but as the week progressed became ill with what the family assumed was gastric flu.
By the Thursday he was vomiting, with diarrhoea and fever, and spent the following day at home in bed. Karen called the family doctor, who recognised a post-surgical infection and prescribed antibiotics.
But it was already too late. The infection was out of control and standard antibiotics were not enough. That Saturday morning, eight days after the operation, Jem woke up delirious, with blue lips and uncontrollable diarrhoea.
Karen called an ambulance, uttering soothing words as her partner of 20 years was taken away, while she followed behind with his nightclothes.
It was to be the last time she spoke to him. By the time she arrived at the hospital she was told her husband had suffered a massive heart attack because of septicaemia.
He had been put on a life-support machine and doctors were battling to save his failing organs.
Karen was warned the circulation was failing in his limbs. She was told to expect amputation of his fingers and toes, which had already been irreversibly damaged.
As her husband's condition worsened over the following two days, the doctors said they would need to remove all four limbs. Karen was also told Jem would be brain damaged.
"I knew he wouldn't want to be alive like that," she said. "He was a proud man, a great water-skier, the life and soul of the party."
But the decision about whether to switch off the life-support machine was made by the doctors the following Tuesday.
They said his heart and other major organs were so damaged by the bacterial invasion that they would not sustain him. Jem died ten days after the vasectomy in March 2004.
"It was so quick, it was impossible to take in," said Karen, who is now 42, and has moved back to her parents' home with the children.
"I had no idea septicaemia could kill young, fit people. I thought only frail hospital patients were at risk.
"We had to wait a year for the inquest. They couldn't tell what the original bacterial infection was because, by the end, he had been given so many antibiotics they masked which bacteria had killed him.
"The coroner said that while septicaemia was the cause of death, there was no way of knowing where it had come from."
Her husband's death was not attributable to any particular wrongdoing. A vasectomy involves making a tiny incision to cut and tie off the ends of the tubes which carry sperm from the testicles.
Jem's fatal infection had apparently been caused by bacteria getting into the wound site, but there was no explanation for how it had happened.
It could not be argued that the family GP had failed in his duty. Septicaemia kills rapidly.
The condition he had observed in Jem showed no outward sign of being a fatal infection, and he had given antibiotics correctly.
There are thousands of similar tragedies every year. Although the frail and sick are at much greater risk, there have been fatal cases in babies and children, and even in people undergoing minor dental procedures.
It's thought that some, like Jem, may simply be genetically more susceptible to bacterial infection.
Gene mapping has already identified one common gene variation which means some people may be at greater risk if they are exposed to an infection.
There are fears that a new wave of infections is being caused by the so-called antibiotic-resistant superbugs like MRSA.
However, microbiologists say infections with varieties of streptococcal bacteria can spread much faster and be more lethal than superbugs.
Although septicaemia, or blood poisoning, is recognised as a major cause of death, it often is not mentioned on death certificates.
Instead doctors simply write more general diagnoses such as pneumonia or perforated bowel because patients have not even been tested for bacterial infection.
According to a new pressure group of worried senior doctors and nurses, called Survive Sepsis, it is this lack of attention which has led to the condition being widely unrecognised.
They are launching education campaigns in hospitals to make doctors and nurses aware of the 'golden hour' before the infection overwhelms the body, and when treatment can still be effective.
They are being urged to perform six key procedures as soon as the patient arrives in hospital, which research has proved will make the difference between life and death.
These elements of extra care include giving oxygen, antibiotics and fluids; taking blood cultures to identify the specific bacteria involved; monitoring blood characteristics and checking urine output.
Although this extra care is sometimes offered in septicaemia cases, there are fears that too often it is not even considered. If Jem had been sent straight to hospital before the fatal weekend, he might not have died.
The Survive Sepsis campaigners are hoping that raising awareness among GPs and the wider public will save lives. So far 12 hospital trusts have sent staff to the Survive Sepsis training course and have implemented the new septicaemia treatment guidelines.
Ron Daniels, an intensive care specialist at the Good Hope Hospital in Sutton Coldfield, and regional co-ordinator for the prevention of infectious diseases in the West Midlands, is spearheading the UK arm of Survive Sepsis, which is part of a 14-nation effort.
Dr Daniels' own hospital team has already proved the effectiveness of rigorously using the six-step plan.
In a three-month investigation of the treatment of 101 infected patients, it was found that almost three-quarters of those who received all six treatment elements survived the infection.
Dr Daniels points out that a similarly diligent application of procedures for treating heart attacks has reduced mortality to one in 20.
If a similar approach was taken to septicaemia, there would be an equally dramatic drop in cases.
"We have a target time of one hour to apply the procedure to prevent sepsis. The international target for the campaign is to reduce sepsis deaths by 25 per cent, but I think it should be possible to save many more - perhaps 10,000-20,000 people a year - by doing these straightforward things," he said.
One of the problems of getting people specialist help in Britain is the lack of intensive care beds.
In terms of population, Britain has only ten per cent of the number of intensive care beds available in America, and half the number available in countries such as Denmark or Germany.
Doctors and nurses are regularly forced to carry out heroic life-and-death struggles to save septicaemia patients under the gaze of general patients on open wards.
A study published three years ago in the British Journal of Anaesthesia said that although critical care and high dependency beds had increased since the millennium, the facilities could still not meet the rising demand.
"There is evidence to suggest that many British surgical patients could benefit from access to a critical care area but are denied it," the report said.
Nor is the problem simply about money. Intensive care doctors say that despite the fact septicaemia is so serious, treatment of it has never been the subject of any NHS target, so hospital managers have no incentive to divert resources to tackle it.
"These are not 'must-do' priorities for hospital administrators," said Richard Beale, the clinical director of perioperative and critical care at Guy's and St Thomas' in London.
"Managers don't know how many of their patients die from sepsis and they are not accountable for it."
Patrick Nee, an intensive care consultant at Whiston Hospital in Liverpool, agrees that part of the problem is there is no national requirement for doctors to collect statistics on septicaemia deaths.
"A lot of them happen in nursing homes as well as on open wards and are never recorded as sepsis, they just get put down to things like pneumonia," he said.
"If every single hospital started following these guidelines we would have a chance of starting to improve survival rates."
This May, the National Patient Safety Congress will hear argument that the Surviving Sepsis guidelines should be applied to all hospitals as a matter of urgency, and that greater funding should be made available for nurses and other staff to attend the training programmes to alert them to the signs.
"There is no question that raising the profile of the problem in this way would make a considerable difference to the way septicaemia is viewed," said Ron Daniels.
"Let's hope that as a result of this meeting and the international initiative, things finally start to move."
"No one wants to see people die needlessly, especially young people," said Karen Abbott.
"The hospital staff tried everything they could to save Jem. The fact is that it was already too late. If more people were aware, they could act sooner.
"I don't want him to have died in vain. I want people to know about this so they can save their loved ones."
