Trust failed to spot signs of sepsis

What happened

Mr L was taken to hospital from his care home in the early hours of the morning when he became unwell and breathless. He was seen in the emergency department but was assessed as being safe for discharge back to his care home with some antibiotics. Mr L died the following day. His cause of death was recorded as sepsis.

Mr L's wife complained to the Trust and said that if her husband had been admitted for treatment, he might have survived. The Trust told Mrs L that an admission would not have made any difference and that he was discharged appropriately. Mrs L asked us to investigate.

What we found

We found that the Trust did not properly consider all of the clinical information available to them and did not investigate alternative diagnoses. The severity of Mr L's condition and the possibility he had sepsis should have been recognised and Mr L should have been admitted to hospital for treatment. Because Mr L's full diagnosis was not known, we could not say for certain whether his death was preventable. However, Mrs L suffered distress as a result of her husband's inadequate treatment and because it was not possible to say whether or not he might have survived.

Putting it right

The Trust has apologised to Mrs L and has paid her compensation of £2,000. It has agreed to create an action plan addressing the failings we identified.