Poor communication led to delay in diagnosing sepsis

What happened

After a referral from his GP, Mr D attended a haematology clinic. Staff took blood for testing, but Mr D left the clinic before the blood results arrived. Staff found abnormalities in the test results that needed further investigation.

A consultant attempted to contact Mr D to advise him to go straight to A&E for intravenous antibiotics and vitamin K, and to stop taking his warfarin medication straight away. However, it was approximately three to four hours before anyone could contact Mr D so that he could go to A&E.

When he arrived at A&E, staff were not aware of Mr D's condition and there was a delay in getting him the antibiotics he needed and treating him for sepsis. He was transferred to a ward and then the intensive care unit. Mr D sadly died the next day.

What we found

There was a delay in Mr D's diagnosis of sepsis, and there were failings in the way that the Trust responded to Mr D's family's complaints.

We are not reassured that the Trust has learnt from what happened, or has put processes in place to make sure that the failings will not happen again. This is potentially significant because, although we could not say that in Mr D's case the delay caused his subsequent death, this may not be the case in the future for other patients.

We have noted the work that the Trust has done in response to what happened to Mr D, and we do not doubt that it has already made improvements. However, there are outstanding issues that have not yet been addressed, so we partly upheld Mrs A's complaint.

Putting it right

The Trust wrote to Mrs A acknowledging that it did not address all of her complaints and apologising for this. It gave Mrs A details of the improvements it has made following her complaints and how it is monitoring these.

It also completed an action plan to address all of the failings found in the report. It shared this with us, Mrs A, the Care Quality Commission and Monitor.

Although we also recommended a financial payment of £1,000 for the distress caused by having to pursue the complaint, the family have said that they will not accept this payment.