48-hour delay in diagnosing and treating signs of sepsis
The complaint
Mrs G complained about the care and treatment that Leeds Teaching Hospitals NHS Trust gave her late grandfather, Mr H, after he fell at home in 2018.
The Trust initially treated Mr H for a suspected stroke but moved him to a respiratory ward due to concerns about him becoming increasingly breathless. He received treatment for a pneumothorax (a collection of air outside the lung causing the lung to collapse). He was assessed as having a moderate risk of sepsis and sadly died two days later.
Mrs G complained that the Trust did not diagnose or treat signs of sepsis, which was recorded as Mr H’s main cause of death.
What we found
The Trust was monitoring Mr H’s National Early Warning Score while he was in hospital. (NEWS is a system used to assess and respond to acute illness, including sepsis – the current version was updated in 2017 and is called NEWS2.) When his NEWS had risen to five, the point at which sepsis should be considered, the Trust completed a sepsis screening tool and assessed Mr H as having a moderate risk.
The Trust says it considered that a pneumothorax found on an X-ray was the cause of Mr H’s health getting worse. It inserted a chest drain to treat the pneumothorax.
Later that evening, Mr H’s NEWS had risen to nine. His scores included a high temperature and a low blood pressure level that suggested a possible underlying infection. Records did not show that the Trust recognised the possibility of infection at this time or investigated it further.
Two days later, Mr H’s blood test results showed an increased lactate measurement (increased lactate in the blood can be a sign of sepsis). The Trust prescribed antibiotics. By the time the prescription was ready it decided not to give Mr H the medication because his health continued to get worse.
The Trust did not measure Mr H’s lactate levels when his NEWS had risen to nine. It should have done this, following NICE guidelines. If it had, it would likely have produced a result like the measurement taken two days later.
There was a 48-hour delay in the Trust identifying the possibility of sepsis and prescribing antibiotics for Mr H. This failing seriously affected his chances of survival.
Putting things right
We said the Trust should write to Mrs G accepting and apologising for the failure to diagnose and treat her grandfather’s sepsis.
We also said the Trust should tell us and Mrs G how it will address the failing and reduce the risk of this happening again in the future.