Failure to act on sepsis led to man’s death, Ombudsman finds

A man died after an NHS trust failed to diagnose and treat sepsis quickly enough, a Parliamentary and Health Service Ombudsman investigation has found.

Stephen Durkin, a factory worker from Hereford, died after suffering organ failure from sepsis. The life-threatening condition occurs when the immune system overreacts to an infection, causing widespread inflammation that can damage the body’s own tissue. Stephen’s wife Michelle made a complaint to the Ombudsman after she was left floored by his sudden death which she believed was avoidable.

Stephen was an otherwise healthy 56-year-old when he attended Wye Valley Trust A&E in July 2017 with chest pain. Hospital staff suspected he had a major blood vessel blockage and admitted him to a ward overnight. The next morning his overall condition had worsened but staff did not monitor him more closely, as national guidance advises, and he continued to deteriorate throughout the day.

The next day Stephen was admitted to intensive care and treated for sepsis but tragically died later that evening. In the space of 48-hours his condition deteriorated rapidly but staff did not act quickly enough and the critical care team attended Stephen ten hours too late.

His wife Michelle arrived at the hospital to visit Stephen, only to find that he was critically ill and unresponsive. She was left devastated by his death and turned to the Ombudsman to look into what had happened with his care.

She said:

My feelings regarding his death cannot be expressed fully in words. Stephen’s death was untimely and avoidable, he had so much to live for.

I’m hoping that highlighting the mismanagement of Stephen’s treatment and care by Hereford hospital, which resulted in his death, can prevent anyone else from experiencing the same tragic journey myself and family have had to take.

Ombudsman Rob Behrens said:

Stephen’s tragic death could so easily have been avoided. His case shows why early detection of sepsis, as set out in national guidelines, is crucial.

Sadly, this is not the first time we have had to highlight this issue. There is clearly more the NHS needs to do. It is vital that NHS trusts ensure their staff are sepsis-aware to reduce the number of avoidable deaths from this life-threatening condition.

Following the investigation, and at the Ombudsman’s request, the Trust has provided extra training to its staff in sepsis management and advanced communication skills. It explained that since doing so, it has seen a ‘considerable reduction’ in sepsis-related deaths, demonstrating how complaints can lead directly to service improvements in the NHS, and better outcomes for patients.

The Ombudsman’s findings mirror those of another recent investigation which found a woman died after sepsis was not identified and treated quickly enough. In this case, antibiotics to treat sepsis were given four hours later than they should have been, reducing the woman’s chances of survival by 30%. Again, national guidelines were not followed, despite the fact that early action on sepsis is vital.

Read the case summary.