Trust failed to take action when it suspected sepsis

What happened

MrsP was readmitted to hospital as an emergency after minor orthopaedic surgery.  She deteriorated, and after various medical investigations in A&E, doctors found that she had possibly developed sepsis but they failed to escalate their concerns to more senior staff.

The next morning doctors in A&E conducted their morning review and should have realised Mrs P was very ill. There were signs of sepsis, but the consultant failed to note this or act on it. Mrs P deteriorated during the day and 12 hours later doctors suspected she had sepsis and transferred her to intensive care.  She was then diagnosed with severe sepsis and began antibiotic treatment. Despite this, she suffered cardiac arrests and died.

Mr P complained to the Trust as he believed his wife's life could have been saved. He raised several issues, including that Mrs P was inappropriately discharged after her orthopaedic surgery and this led to her emergency readmission.

The Trust conducted a Serious Untoward Incident (SUI) investigation and found many shortfalls. It said doctors failed to escalate concerns about Mrs P's condition to senior colleagues when she was in A&E, the consultant in A&E did not act on signs of sepsis and start treatment, and there was poor communication between staff.

It shared its action plan and recommendations with Mr P but he was not satisfied with the thoroughness of the answers he received, and came to us.

What we found

We partly upheld this complaint. The Trust had already carried out a thorough SUI investigation with senior clinical staff and agreed it had failed to escalate concerns about possible sepsis, or to appreciate the severity of Mrs P's condition. We agreed that the Trust had identified the main shortfalls, but we found the actions the Trust had taken to prevent a recurrence mainly centred on nursing staff rather than the doctors, including the consultant. We therefore recommended the Trust address this with the doctors, and take further action to reinforce what it had learned from its SUI.

We did not uphold Mr P's complaint that his wife had been inappropriately discharged.

We concluded that the Trust had the opportunity to treat the sepsis but did not do so. This caused Mr P distress, as there remained the possibility that there could have been a better outcome for Mrs P if doctors had treated the sepsis earlier, but we could not say that Mrs P's life could have been saved.

Putting it right

The Trust discussed the case in a clinical governance meeting and raised our findings in the consultant's appraisal process.