Busy A&E department did not clinically review man with signs of sepsis within a reasonable time

What happened

Mr L went to A&E at around 8pm due to breathing difficulties. Staff started him on intravenous antibiotics at around 11pm and transferred him to the medical admissions unit in the early hours of the following day.

What we found

An assessment nurse saw Mr L within a reasonable time and took observations. However, these observations warranted an early clinical review because Mr L showed signs of sepsis. Instead, Mr L was not reviewed by a doctor for three hours.

While the overall clinical assessment was reasonable, the Trust failed to undertake a blood gas analysis. Had it done so, it is probable that Mr L would have been given oxygen sooner. As it was, he was in avoidable distress for a number of hours.

While the Trust had already apologised for the delay, it had not done enough to find out what went wrong or to learn from the incident.

Putting it right

The Trust apologised to Mr L. It reviewed the way that national early warning scores had been calculated in this case in order to find out why the scores were incorrect. The Trust told Mr L about its system for making sure that clinically urgent cases are seen in an appropriate timescale at very busy times, and about how this is monitored. It also agreed to produce an action plan to address its failings.