Woman’s death was avoidable, Ombudsman finds

A 62-year-old woman could have survived a severe infection called sepsis had she received proper care at a London-based hospital, an investigation by the Parliamentary and Health Service Ombudsman (PHSO) has found.

The woman went into Imperial College Healthcare NHS Trust suffering from abdominal pain and blood in her urine but following inconclusive tests was discharged.

She went to hospital several more times because of her pain and was eventually admitted for exploratory surgery but before this could take place her condition worsened and she died.

Parliamentary and Health Service Ombudsman Julie Mellor said:

Our investigation found that because of a series of errors at a hospital a woman lost her life.

'Her husband told us that he has lost his best friend just before he and his wife were due to start a new life together.

'Our investigation found that staff had made errors in adequately assessing the woman's condition, treat her with appropriate antibiotics in enough time, or to take enough steps to control the clotting of her blood before surgery. Nor should it have discharged the woman after her admissions. The Trust's complaint handling was also poor.

'We hope our investigation and the action taken by the Trust will reassure him that lessons have been learnt as a result of his complaint so that others are less likely to suffer the same experience.'

In a similar case another investigation carried out by the PHSO found that a Surrey-based hospital's failures reduced an elderly man's chances of survival from sepsis.

The 77-year-old man was admitted to Ashford and St Peter's Hospitals NHS Foundation Trust with several health problems.

The investigation found that although he was managed appropriately once he was in the care of the medical team, the care he received during the initial period did not meet the expected standard.

His condition was not recognised for more than two hours until he was seen by a doctor, who suspected he might have sepsis while antibiotics were not started until four hours after admission.

This reduced his chances of recovery. The Trust agreed to pay his daughter £1,200 in compensation for the distress and to acknowledge and apologise to her for the failings and injustice caused and to identify what service improvements might be needed.

His daughter said:

My father went into hospital with sepsis and never returned home again. Nothing in this world can replace him and all the family are devastated by such a loss. After his death, I felt that he did not always receive the best treatment and care he deserved. Because of this, I took the decision to forward my concerns to the Parliamentary and Health Service Ombudsman (PHSO) in the hope that others would benefit from this.  

'In my case, I found the PHSO to have acted in a very professional manner, showing kindness, attention to detail and a relentless determination to provide a quality service. I found the investigation to have been carried out promptly, impartial and in a very open and fair way.'

Julie Mellor added:

Sepsis is a treatable condition, but too many people are dying unnecessarily from it because NHS services are failing to spot the warning signs.

'Our report, Time To Act, recommended a combined effort by the health sector was needed to improve the diagnosis and treatment of sepsis.

"This is now being taken forward by a range of health organisations including NHS England, NICE, and Public Health England after the Department of Health made announcements at the end of last year that have the potential to save thousands of lives each year.'

The Parliamentary and Health Service Ombudsman is independent and impartially investigates complaints from individuals about UK government departments, and other public organisations, and the NHS in England. It carries out adjudications making final decisions on people's complaints. The Ombudsman Service investigates 4,000 cases a year and upholds around 42 per cent.

Notes to editors

  1. Sepsis is a time-critical condition that can lead to organ damage, multi-organ failure, septic shock and eventual death. Caused by the body's immune response to a bacterial or fungal infection, it claims 37,000 lives annually in the UK and many more are affected and suffer in the longer term.
  2. In September 2013, we published our first clinical report on sepsis Time to Act. It focuses on ten complaints we investigated about patients with severe sepsis who did not receive the treatment they urgently needed. In every case, tragically the patient died. Our report highlighted what went wrong.
  3. Since we published our report, we have been working with others to help improve NHS care on sepsis. We have partnered with the UK Sepsis Trust and been working closely with NHS England, NICE, the Royal College of Physicians, the Royal College of Surgeons, and the College of Emergency Medicine to find solutions to the issues identified in our report.
  4. At the end of last year the Department of Health announced a series of improvements across the system including a public awareness campaign to be launched by Public Health England.


Contact: Jeremy Dunning