Delay in diagnosing and treating sepsis after a procedure
The complaint
Mrs B complained about the treatment that Sandwell and West Birmingham Hospitals NHS Trust gave her mother, Mrs A.
Mrs A was in her seventies and had existing health conditions including a previous heart attack. In 2018, she went to a clinic for a hysteroscopy (a procedure to look inside the womb). The surgical team identified her as a high-risk patient and booked her into a ward for monitoring. During the procedure, the surgeon diagnosed and drained pyometra (an infection where pus fills the womb).
At 4.15pm, a couple of hours after the procedure, Mrs A had nausea and diarrhoea. Her blood pressure dropped and she had a very low white blood cell count. She was moved to the acute medical unit (AMU) for close monitoring.
The AMU doctor assessed Mrs A at 6.45pm and recommended an immediate dose of antibiotics. This did not happen. The consultant gynaecologist (a doctor who specialises in the female reproductive system) was told about Mrs A’s deteriorating condition at 7.30pm but did not suggest antibiotics. The record of the conversation did not say whether they were told about the AMU doctor’s recommendation.
Mrs A continued to get worse and was given a single dose of antibiotics at 10.40pm. Doctors decided not to move Mrs A to intensive care due to her existing health conditions.
The next morning, Mrs A had a CT scan (a scan that creates detailed images of the inside of the body) and more antibiotics. She was moved to intensive care to get medication to help her heart to pump. She did not get better and doctors started end of life care. She sadly died a few days later and sepsis was one of the reported causes of death, with severe heart failure as a contributing factor. Sepsis can cause multiple organ failure if it is not recognised early and treated quickly.
What we found
We found that the Trust did not give timely treatment for sepsis. There was a significant delay of almost four hours in giving antibiotics. Mrs A should have been given antibiotics when the AMU doctor recommended it. The consultant gynaecologist should have recommended antibiotics. If Mrs A had been given prompt antibiotic treatment in line with NICE guidance, it is more likely than not she would have survived.
We found that the Trust did not move Mrs A to intensive care at the earliest opportunity for her to get life-saving support. There was a misunderstanding about how her treatment should have been escalated after the procedure, because the Trust did not clearly record her post-operative care requirements and agreements.
Mrs A should not have died when she did. This caused her family a lot of distress and affected their ability to grieve.
Putting things right
We said the Trust should write to Mrs B to accept the failings and apologise for how they affected Mrs A’s family. We said it should make a payment to Mrs B to recognise the injustice suffered. We also said the Trust should make an action plan setting out how it will stop the same mistakes from happening again and send a copy of the report to the Care Quality Commission (CQC) and NHS Improvement.