Organisation we investigated: Wye Valley NHS Trust
Date investigation closed: 23 January 2020
The complaint
Michelle Durkin complained about delays in the diagnosis and treatment of sepsis which led to her husband Stephen’s death. She said that the Trust did not carry out proper observations, put him under the critical care team or transfer him to intensive care quickly enough. She also complained that the Trust did not communicate effectively with her about her husband’s condition which meant she was unable to say goodbye to him.
Background
On 31 July 2017, Stephen Durkin was admitted to the Trust’s emergency department with chest pain. Later that day, he was transferred to a ward with a suspected pulmonary embolism (PE), which is a blockage in a major blood vessel.
The next morning, Stephen was reviewed by a nurse and junior doctor, then a consultant. They concluded that he had a PE and a lung lesion and his National Early Warning Score (NEWS) was seven. NEWS is a tool used to identify and respond to patients at risk of clinical deterioration. According to national guidance, it is essential for a patient with a NEWS of seven or more to be assessed by a critical care team, but this did not happen. Later that morning a specialist registrar requested Stephen had several chest scans and tests and he was referred to urology.
Nursing staff monitored Stephen throughout the day, recording that he had a raised temperature and NEWS of between seven and nine. By 7pm his condition had worsened, and his NEWS was ten. A junior doctor suspected Stephen might be suffering from sepsis so he was given IV fluids. Sepsis is a life-threatening condition that occurs when the immune system overreacts to an infection and starts to damage the body’s own tissue.
The next morning, Michelle phoned the ward to ask how her husband was. She was told he had been in pain but had taken medication and was sleeping. Later that morning, Stephen’s mother called the ward and was told that he was very ill. A nurse did not phone Michelle to tell her Stephen had been transferred to intensive care until 45 minutes after she had informed Stephen’s mother about his condition. Michelle went to the hospital and on arrival was told her husband was being treated for sepsis. His condition had deteriorated and he was unresponsive. Later that day, Stephen sadly died of severe multiple organ failure caused by sepsis.
What we found
Our investigation found that the Trust should have detected sepsis earlier than it did. The Trust did not follow its own deteriorating patient policy to observe the patient every four to six hours within the first 48 hours. National guidance on NEWS states that if the NEWS increases, the frequency of observations should also increase. By the time the Trust saw Stephen, his NEWS had increased significantly. It is highly likely that more frequent observations would have detected this deterioration earlier, which would have prompted the Trust to consider how to treat Stephen’s worsening condition.
We found that even when the Trust did detect the deterioration, it did not react appropriately. According to national guidance, it is essential for patients with a NEWS of seven or more to be assessed by a critical care team. The Trust did not do this until ten hours later, when Stephen’s NEWS was nine.
We also found that the Trust did not effectively communicate with Michelle about her husband’s condition. When she called the ward, she was not told how unwell he was. If she had been, she could have got to the hospital sooner. We found this would have given her an opportunity to better prepare herself for what was to come, but this option was taken away from her.
Putting it right
Following our recommendation, the Trust has agreed to:
- write to Michelle to acknowledge the failings identified in our report and apologise for the impact they had on her
- explain what action it will take to ensure all relevant staff involved in Stephen’s care receive training in sepsis awareness
- pay Michelle £17,000 in recognition of the injustice she suffered as a result of its failings.
Read the press release.