Failings in care and treatment of a man with sepsis reduced his chances of recovery

What happened

Mr C, who was in his seventies, went to hospital with an infection. Nursing staff assessed him when he arrived and a doctor saw him nearly two and a half hours later. The doctor suspected that Mr C might have sepsis (a life‑threatening condition that arises when the body's response to an infection injures its own tissues and organs) and decided he should stay in hospital. Mr C had his first dose of antibiotics two hours later.

The next day, clinicians started Mr C on a more intensive regime of antibiotics and took advice on treatment from the hospital's microbiologists. Staff then transferred Mr C to the intensive treatment unit. He died the day after that.

The cause of Mr C's death was 'sepsis with multi‑organ failure'. The Trust had not identified the source of the infection by the time of Mr C's death, but had found a number of possibilities including a chest infection or an infection in the biliary system (the organs and ducts that produce and transport bile, which helps break down fats in food).

Mr C's daughter, Mrs P, complained about her father's care and also about the information on his death certificate.

What we found

Although Mr C was managed appropriately once he was in the care of the medical team, his initial care did not meet the expected standard. A doctor did not see Mr C for more than two hours, staff did not carry out his physiological observations and clinicians did not give him antibiotics until four hours after he arrived at the hospital. In short, the clinical staff who saw him soon after he arrived in hospital did not recognise the severity of his illness. This reduced his chances of recovery.

The information included on the death certificate was not unreasonable, given the clinical circumstances and the uncertainty about the precise cause of Mr C's sepsis. It is unfortunately not possible to resolve this.

Putting it right

The Trust agreed to acknowledge and apologise to Mrs P for its failings, and to identify ways to improve its service. The Trust also paid Mrs P £1,200 compensation.