Failure to treat sepsis before and after a fall in hospital
The complaint
Mrs C complained about the care and treatment that Blackpool Teaching Hospitals NHS Foundation Trust gave her mother, Mrs D, in November 2017.
Mrs C found her mother unwell at home. In hospital, she was diagnosed with worsening chronic obstructive pulmonary disease (COPD is the name for a group of lung conditions which cause breathing difficulties) and moved to the acute medical unit.
Almost two weeks later, Mrs D fell while still in hospital. She had a cardiac arrest (where the heart stops pumping blood around the body) the next day. Mrs D did not recover and sadly died.
Mrs C says her mother died avoidably and unexpectedly from pneumonia and a cardiac arrest because the Trust missed opportunities to provide the care she needed. She was devastated when her mother died, and this has caused her long-term and ongoing upset and anger.
We saw an internal Trust document, written after the events, where a medical consultant wrote that Mrs D was ‘clearly unwell’ after her fall ‘and had shown a very rapid deterioration within a short period of time which was likely due to developing … pneumonia with sepsis secondary to her severe underlying lung disease’. We did not see any evidence that the Trust shared this information with Mrs C.
What we found
We found that Mrs D had signs of sepsis and the Trust missed opportunities to identify and treat it.
A CT scan suggested that Mrs D had pneumonia (inflammation of the lungs) when she arrived at hospital. She was treated with antibiotics and her condition improved. The Trust stopped antibiotics after the five-day course.
A few days after the course was finished, blood tests showed that Mrs D had acidaemia (when the lungs cannot get carbon dioxide out of the body quickly enough) and type two respiratory failure (low oxygen levels and a build-up of carbon dioxide). A chest X-ray the next day showed that Mrs D’s health had deteriorated since being admitted to hospital. There was a new pleural effusion (fluid around the lungs) and worsening consolidation (when the air spaces in the lung are filled with something other than air). Our clinical adviser said these results were likely caused by worsening pneumonia and suggested that Mrs D had recurring sepsis. The Trust should have suspected sepsis and restarted antibiotics.
Our clinical adviser also said sepsis was likely the reason Mrs D fell the day before she died. Mrs D had high NEWS scores, low oxygen levels and a high respiratory rate, which meant she was in the high-risk category for suspected sepsis.
There was no evidence that the Trust considered sepsis as a medical reason for the fall, escalated the concerns to a doctor, or took the actions it should have done in line with the Trust’s and NICE guidance on sepsis. A medical consultant reviewed Mrs D later that morning and wrote a plan to consider restarting antibiotics, but the Trust did not prescribe them until 6pm.
The Trust’s failings meant that it missed opportunities to treat sepsis, which might have prevented Mrs D’s worsening health, fall, cardiac arrest and death.
Putting things right
We recommended that the Trust write to Mrs C to accept and apologise for the failings in Mrs D’s care and explain how it will stop them from happening again. We recommended that it make a payment to Mrs C to recognise the injustice that she and her family will never know whether things could have been different.