Sepsis caused by poor discharge and lack of follow-up
The complaint
Mr M complained about the care and treatment that George Eliot Hospital NHS Trust gave his partner, Ms R.
Ms R was diagnosed with an aggressive type of bowel cancer and had surgery to remove part of her bowel. The wound did not heal well and she developed abdominal abscesses so she stayed in hospital. After the second abscess was drained, Ms R was discharged home with a wound bag over it to collect fluid and pus. She did not have a drain in place and did not receive a follow-up outpatient appointment to review her ongoing treatment.
Ms R went back to hospital around two months later with a large abdominal abscess and septic shock. On the day of her emergency admission, the Trust surgically drained 1.5 litres of pus. In the days that followed, Ms R had a cardiac arrest, continued to get worse and sadly died.
What we found
Although Ms R was seriously ill with cancer, it did not appear to have caused her death.
We found that the Trust did not follow relevant guidelines and did not discharge Ms R with a drain in place for the abscess when it should have done. It was more likely than not the lack of drain caused a large build-up of fluid and pus in her abdomen. This led to Ms R developing sepsis and septic shock, which led to her death.
The Trust did not arrange outpatient appointments in line with the relevant guidelines, which increased Ms R’s risk of developing sepsis. If the Trust had arranged a follow-up, it could have identified that Ms R did not have a drain and taken steps to put its mistake right. This was a missed opportunity to prevent Ms R’s avoidable death.
Putting things right
We said the Trust should accept the failings and write to Mr M to apologise. We said it should complete an action plan looking at how these events happened and how it will avoid them in the future. We also recommended that the Trust make a payment to Mr M to recognise Ms R’s avoidable death and the distress this caused.