A 45-year-old man with disabilities could still be alive if he had been given antibiotics earlier, an Ombudsman investigation has found.
The father-of-two died after he was referred to hospital for intravenous (IV) antibiotics for a urine infection but had to wait 34 hours for the medication. By the time he received the antibiotics it was too late and he died from sepsis.
The Parliamentary and Health Service Ombudsman (PHSO) found that his death was avoidable.
The man lived in supported accommodation in Ollerton, Nottinghamshire, and had a rare, incurable disorder called Alexander’s Disease which affects the nervous system. He had respiratory and mobility issues and needed 24-hour care and help with feeding and personal hygiene.
Due to his condition, the man had a permanent catheter and was susceptible to Urinary Tract Infections (UTI). In November 2022, he contracted a UTI that was resistant to oral antibiotics and was referred by his GP to Bassetlaw Hospital for IV antibiotics.
His disabilities meant he had difficulties communicating with staff and raising the lack of treatment, and he was reliant on clinicians to give him the right treatment at the right time. His mother raised concerns about her son’s treatment with staff at the time but she was never told that he had not received the antibiotics he had been sent to hospital for.
This tragic case highlights issues in sepsis awareness and the importance of listening to patients and their families, particularly if a patient has difficulties communicating.
PHSO has repeatedly raised concerns around avoidable deaths and sepsis. Including reports in 2013 (Time to Act) and 2023 (Spotlight on Sepsis) that highlighted the same mistakes, such as delays in diagnosis and treatment, poor communication and record-keeping, and missed opportunities for follow-up care, were putting lives at risk.
Rebecca Hilsenrath KC (Hon), Chief Executive Officer of PHSO, said,
In this case, a man who was unable to advocate himself and completely reliant on clinicians to look after him did not receive the care he needed. Tragically, this meant he unnecessarily lost his life.
“Losing a life through sepsis should not be an inevitability. But we are seeing the same failings repeated time and time again, and complaints about sepsis have more than doubled over the past five years. We also see poor communication between patients and clinicians and we are focusing our efforts to help improve this throughout the NHS.
“Organisations must be held to account so that justice can be provided, and services can be improved for the future. The NHS needs to have a culture that is open, listens to patients and their families, accepts mistakes when they happen, and learns from them.
“This learning should then be shared by Trusts collaborating together to embed potentially lifesaving changes throughout the NHS. It is the responsibility of NHS leadership to build this environment.”
In this case, paramedics and care home staff told the hospital the man needed IV antibiotics. Test results by the GP were also uploaded to an online system used by the practice, his care home and another local hospital, however it was not used by the hospital he was taken to. Hospital staff did not follow the request as it was not confirmed in writing by the GP.
Instead, following consultation with a microbiologist, staff decided to try an oral antibiotic, but the requested drug was unavailable.
At that point, the Ombudsman found that doctors should have requested further advice and it is likely that IV antibiotics would have been advised and available.
This did not happen and the IV antibiotic was only given 34 hours after he arrived at hospital, and at half the dosage it should have been. There was also a three-hour delay between the doctor requesting the drug and it being administered.
By the time a second dose of antibiotic was given, which was also delayed, the man had become septic. He died a week later.
The Ombudsman recommended that Doncaster and Bassetlaw Teaching Hospitals NHS Foundation Trust should write to the man’s mother to acknowledge their failings and apologise.
The Trust should also make an action plan to prevent the same thing from happening again and pay the man’s mother a financial remedy. The Trust has agreed to comply.
The man’s mother, 70, said,
I knew my son better than anyone and I was trying to help the doctors by telling them the oral antibiotic wouldn’t work and that the GP had a microbiologist’s report that said he wouldn’t respond to that drug. But they just totally dismissed me. Their attitude was they were the doctors and I was just his mum.
“I had that mother’s intuition when we brought my son home before he passed away that something wasn’t right. But I’ve fought all my life to get him the right care and support, so I was determined to fight for him again and find out what had happened.
“It was heartbreaking to finally understand the truth. I was given the impression he had at least been given some antibiotics, even if they weren’t the right ones. But to find out he was in hospital for all that time with no treatment was very hard.
“It won’t bring my son back but it has given me closure and no one else should have to go through the same thing now that the Trust has been held to account.”
Dr Ron Daniels, Founder of UK Sepsis Trust, said,
It is more than a decade since the Ombudsman first reviewed the poor reliability of care for people with Sepsis with the report A Time to Act, and just last month NICE reminded us that people who communicate differently often receive worse care.
“This report highlights that it is imperative that health professionals not only take sepsis seriously but also listen to the concerns of families and carers. Everyone deserves the very best chance of surviving sepsis unless it occurs at the very end of natural life, given the significant attention sepsis now receives I find it hard to justify inaction."
Read the investigation report.