Mr F had a history of diabetes, severe kidney failure and other significant illnesses. He went to the Trust as an emergency with vomiting and bleeding and died the same day of sepsis.
What happened
When he arrived in A&E, Mr F was not properly triaged. Doctors had difficulty getting a vein to take blood samples. The delay in getting blood samples meant that there was a corresponding delay in diagnosing sepsis. Mr F was admitted to the high dependency unit, but deteriorated rapidly. The Trust did not consider that life support would be beneficial for him and he died about ten hours after arriving in A&E.
What we found
A doctor should have seen Mr F within ten minutes of his arrival at A&E (rather than an hour and 20 minutes later). Staff should have taken him to the resuscitation area, and used a different technique to get blood samples. Staff did not take blood samples until three hours and 40 minutes after Mr F's arrival. Although there were delays in caring for Mr F and diagnosing and treating his sepsis, we found that this made no difference to the eventual outcome.
Putting it right
We recommended that the Trust apologise to Mr F's wife who brought the complaint and produce an action plan to prevent it happening again.
Northampton General Hospital NHS Trust
Northamptonshire
Came to an unsound decision
Apology
Recommendation to learn lessons or draw up an action plan