Failure to react to signs of sepsis meant opportunity to save life was missed

Organisation we investigated: Barts NHS Foundation Trust

Date investigation closed: 14 November 2019

The complaint 

Complainant P complained about the care provided by Barts NHS Foundation Trust (the Trust) to their parent, Person U. Person U attended hospital for a colonoscopy, but developed a temperature and their condition deteriorated. Complainant P complained that the Trust did not respond to the deterioration. Person U subsequently died.

What we found 

The Trust failed to escalate and properly manage Person U’s condition in the 24 hours after they first became ill. Antibiotics were not provided until 18.5 hours after the first signs of severe sepsis had emerged. Antibiotics should be given within one hour.

This delay meant that Person U’s chance of survival was reduced. We could not say that, had treatment been provided at the right time, Person U would have survived. Person U had pre-existing health conditions, which meant that once infection had taken hold, their chances of survival were reduced. However, the long delay compounded that, reducing the chance of survival further.  

Furthermore, as the Trust had lost Person U’s medical records, we had to rely on the information in the Trust’s Serious Incident investigation. The Trust also did not send the Serious Incident report to Complainant P for four years. The failings in Person U’s care and the delay in providing explanations to Complainant P contributed to their shock and grief at Person U’s death.


Person U went to hospital for a colonoscopy. They had a history of insulin dependent diabetes, anaemia and stroke, which had caused them to need a wheelchair. The colonoscopy was unsuccessful because the bowel had not been fully cleared. Instead, Person U had a CT pneumocolon (a virtual colonoscopy using X-rays to produce images of the bowel).

Person U was supposed to have been discharged from the hospital after the colonoscopy. On return to the ward, however, they became ill with a high heart rate, low blood pressure and a spike in their temperature. They remained on the ward for two days, before being moved to the adult critical care unit (ACCU) for more intensive treatment. Tragically, Person U did not improve and died five days later. The cause of death was sepsis, relating to ‘unspecified gastroenteritis and colitis of infectious origin’ (an infection causing inflammation of the intestine and colon).

A member of nursing staff raised concerns with the Trust about Person U’s care. The Trust undertook a Serious Incident investigation but did not share the report with Complainant P until four years after it was completed. By the time the complaint was brought to us, the Trust had lost all Person U’s paper medical records and most information relevant to the case.

Putting it right 

We recommended the Trust:

  • Write to Complainant P to acknowledge the failings in Person U’s care, apologise and explain the learning it had taken from the complaint to improve its service.
  • Pay Complainant P £7,500 in recognition of the emotional distress caused by the failings in Person U’s care and delay in providing explanations.

The Trust complied with our recommendations.

This case summary is featured in the Ombudsman's Casework Report 2019.