Menu
Search

Time to Act: Severe sepsis - rapid diagnosis and treatment saves lives

Case stories

Ten examples from our casebook of stories where failure to rapidly diagnose and treat severe sepsis has had tragic consequences.

Mr F’s story

Mr F was 37 and married with two young children. When he was admitted to hospital with fever, aches, pains, sickness and other symptoms, staff initially failed to realise just how ill he was. He died the next day.

What happened

Mr F had become increasingly unwell over a five-day period, with fever, aches and pains, diarrhoea and vomiting, dizziness, and breathlessness. His GP referred him to hospital. 

When he arrived at hospital, he had a very rapid pulse, although his temperature was then normal; his blood pressure was low; and he was breathing quickly. The nurse told the doctor about the observations, and he asked for an ECG test before seeing him. Mr F was not seen by the doctor until one and a half hours later. The doctor noted that Mr F was not passing urine, had poor circulation, a rash, and swollen glands. Routine blood tests indicated that Mr F had an infection and advanced acute kidney failure. Intravenous fluids began and the emergency department consultant requested that Mr F was treated as an urgent medical and critical care case. 

More than three hours after he had arrived at hospital, Mr F was seen by a middle grade doctor and half an hour later by the medical consultant. It was only at this point that Mr F was diagnosed with severe sepsis, and he was given antibiotics and more fluids. 

More than eight hours after admission, Mr F was moved to intensive care. By then, he was desperately ill. He was given drugs to stimulate his circulation, and two hours later was anaesthetised and put on a ventilator. He collapsed, but staff were able to resuscitate him.  However, he became increasingly unstable and tragically died that night.  

The post mortem examination showed that Mr F had died of overwhelming sepsis. 

In severe sepsis, fluid resuscitation is for right now, not later.’
The UK Sepsis Trust

What we found 

We found that during Mr F’s first two hours in hospital, the severity of his condition was not recognised. Hospital staff failed to act on his severely abnormal vital signs and there was a delay in carrying out all necessary tests and in starting fluids and administering antibiotics. These failings fell substantially short of National Institute for Health and Care Excellence guidance on responding to acute illness in adults in hospital, and guidelines from the Surviving Sepsis Campaign. Although the care given to Mr F improved during the next six hours, he was not monitored frequently enough and there was uncertainty about which consultant was in charge. 

Mr F’s wife felt that her husband’s care and treatment had reduced his chances of survival. She told us that ‘However slim a chance [he] had of recovery I would have liked that 10% to have been safe and secure. Did he have this 10% chance as he walked through the door?’

Mr F was extremely ill by the time he got to hospital and his condition deteriorated so rapidly that it is unlikely that he would have survived, even with ideal treatment. However, we concluded that the hospital’s delays in treatment reduced whatever small chance of recovery Mr F may have had. 

What happened next

Following our involvement, the Trust apologised to Mr F’s wife and paid her compensation in line with our recommendations. 

Mr F’s wife said that she did not want her husband’s life to have been a waste. The Trust took steps to learn from this case. Among other actions, they introduced the modified early warning score system (based on vital sign observations) and revised their care pathway for patients presumed to have sepsis.  More staff were recruited to the emergency department and the intensive care outreach team, and the deployment of on-call clinical staff was changed to ensure their best usage out-of-hours and for the care of acutely ill patients.

Summary of failings against standards

Clinical care

Timely history and examination on admission or referral.
Investigations to determine:
  • Indices of perfusion
  • Indices of infection
  • Source of infection
  • Cultures of blood and other sites.
Regular physiological monitoring using track and trigger systems.
Accurate recognition of the severity of the illness.
Basic resuscitation with:
  • Large-volume fluid therapy
  • Intravenous broad-spectrum antibiotics after taking cultures.

 

Child B’s story

Child B was eight years old. Her family described her as a ‘strong, well loved child, whose weekends were full of her activities, swimming, gymnastics, tap and ballet’. She was discharged from hospital but staff had missed signs that indicated she was seriously ill. She died at home the next day.

What happened

Child B was usually well, but had been poorly for eight days with a dry cough.  On 6 March she developed abdominal pain and vomited eight times. She was taken to hospital that evening. She showed signs that she was generally unwell, and was increasingly tired and lethargic.  

At A&E, triage staff took Child B’s vital signs, noting she had a slight fever and a rapid pulse but was breathing normally and had normal blood pressure. She was seen half an hour later by the emergency department doctor, who noted that her breathing was laboured, but she was thought to be suffering from mesenteric adenitis (inflamed lymph glands in the abdomen, which causes pain) or possibly appendicitis or gastroenteritis. 

Child B was transferred to the children’s ward. Her temperature was high and her pulse had got quicker, and her blood pressure was raised. She was seen by the registrar, who diagnosed her as having a viral infection or tonsillitis. The plan was to give her paracetamol to lower her temperature, and to review her later and allow her home if she had settled. No blood tests were carried out. Later that night, her temperature came down, although her pulse was still very rapid. Her parents were told they could take Child B home with the assurance they could bring her back in if necessary. 

Tragically, Child B collapsed at home the next morning and could not be resuscitated. 

A post mortem examination showed that Child B had developed a bacterial infection that caused left-sided pneumonia, complicated by a collection of pus in her left chest cavity (pleural empyema).

In the words of Child B’s family, ‘Now we are left with the unbearable pain of losing her. Our home is too quiet, empty, and our happy lives together have been shattered’.

What we found 

The registrar missed two factors that should have alerted her to the possibility that Child B was seriously ill. First, the long duration of her illness was not typical of a simple viral illness. Secondly, although Child B’s temperature had come down, her pulse remained very rapid. This suggested sepsis. The registrar should have paid more attention to these factors and carried out further investigations, which might reasonably have included blood tests. The registrar’s assessment of Child B was inadequate, and her diagnosis did not explain all the clinical findings. The reassurance from the fact that Child B’s temperature fell after paracetamol was given, was also misplaced.

Now we are left with the unbearable pain of losing her. Our home is too quiet, empty, and our happy lives together have been shattered.’
The family of Child B

What happened next

At our recommendation, the Trust apologised to Child B’s family, paid them compensation and explained how they would prevent a repeat of their failings. Specific measures put in place by the Trust include developing a paediatric early warning score system, and preparing local clinical guidelines on the clinical management of children with fever. We also recommended that the registrar reflected on our findings and worked with her local clinical tutor to agree and implement a plan to address the specific failings in her care of Child B. 
The hospital has since admitted breaches in the duty of care provided to Child B. 

Summary of failings against standards

Clinical care

Timely history and examination on admission or referral.
Investigations to determine:
  • Indices of perfusion
  • Indices of infection
  • Source of infection
  • Cultures of blood and other sites.
Accurate recognition of the severity of the illness.

Organisation of care

Appropriate and timely senior medical input.

 

Mr H’s story

Mr H, who was 67 years old, developed necrotising fasciitis while recovering from a hernia operation. Hospital staff failed to recognise the seriousness of his condition at an early stage, and he waited more than 16 hours for the emergency surgery he needed. 

What happened

On 2 March Mr H had surgery for a large inguinal hernia descending into the scrotum.  A drain was left in the wound to allow any fluid to pass out. This continued to discharge, delaying his return home.  Mr H’s family remarked on a foul smell from the wound, but this was not mentioned in his health records.  

Mr H was finally discharged on 16 March, but the next day the GP was called because he was generally unwell. Mr H’s son recalled that ‘everywhere he sat in the house, he left a damp patch and foul smell’. The GP sent Mr H to the emergency department, arriving late in the evening. The paramedic recorded low blood pressure. However, the nursing triage assessment was not recorded, and there was no indication that any account was taken of Mr H’s low blood pressure and the urgency of the GP’s concerns.  

Around three hours later Mr H saw a doctor, who noted a large area of dead tissue over his lower abdomen. The doctor realised that Mr H was seriously ill – he had necrotising fasciitis. Mr H was given intravenous fluids and antibiotics, and was referred for emergency surgery to remove the dead tissue. However, surgery was delayed until more than 16 hours after Mr H’s arrival. 

Mr H had extensive surgery to remove the dead tissue, and his postoperative care was complicated and slow. In all, he was in hospital for 15 months and suffered numerous illnesses. One leg was also amputated. Mr H’s son said that his father: ‘had gone from being a relatively healthy man with a hernia to being unable to move far from his chair. He should have been playing with his grandchildren and enjoying his retirement now, but he can’t.’

He said that ‘no amount of money can ever repay my father for his lack of dignity, mobility and pride’ Mr H never fully recovered and died a year later.

What we found 

We found failings in the poor assessment of Mr H when he was readmitted to hospital, the delay in treating sepsis, and the delay in carrying out the emergency surgery. We also criticised the way the Trust dealt with the family’s complaint about Mr H’s care and treatment.

What happened next

In line with our recommendations, the Trust apologised to Mr H’s family and paid compensation to his wife. The Trust also drew up plans to address their failings. Their action plan included implementing the Manchester triage system in the emergency department, and introducing the ‘patient at risk’ and 
pain-scoring systems to improve patient assessment on arrival. They also planned to revise their guidelines for managing sepsis. 

Summary of failings against standards

Clinical care

Timely history and examination on admission or referral.
Regular physiological monitoring using track and trigger systems.
Basic resuscitation with: 
  • Large volume fluid therapy
  • Intravenous broad-spectrum antibiotics after taking cultures
  • Vasopressor therapy if required to maintain adequate haemodynamics and tissue perfusion.
Source control to be performed as soon as possible after initial resuscitation.

Organisation of care

Appropriate and timely referral for source control.

 

Mr D’s story 

Mr D was a 46‑year‑old computer engineer, who taught mathematics, and liked making things for his daughter. His mother described him as a ‘loving and helpful man, not only to the family, but to all who knew him’. Two GPs failed to properly assess his condition. Within days he collapsed and died.

What happened

Mr D had had a sore throat for a week, but then became generally unwell and was shivering uncontrollably.  He called the GP out-of-hours service at 11.19am on 14 February, and a nurse called back at 12.03pm.  Mr D explained his symptoms, describing the pain as being the worst he had ever experienced and how he could not stop shivering.  The nurse arranged for him to see a doctor at a health centre, which he attended within the hour.

The GP who saw Mr D noted his temperature was 39°C, and that he had a white coating on his tongue and palate.  He was aware that Mr D had a history of asthma, and diagnosed oral thrush and prescribed lozenges. Overnight Mr D’s face started to swell so that it was difficult to open his eyes and the glands in his neck were swollen. Mr D’s partner called the out-of-hours service at 1.40pm, and a second GP called her back at 2.16pm. Mr D described his symptoms and said he had trouble breathing and had back pain. Mr D’s breathing troubles can be heard clearly in the recording of this call. The GP asked about his eye problems, and if he could eat and drink. She told Mr D to continue taking paracetamol, and to see his own GP the next day.

The next morning Mr D collapsed and died at home while having a shower. The post mortem examination showed a large collection of pus in his chest cavity (pleural empyema).

What we found 

Both GPs failed to adequately assess Mr D’s condition and to act in line with the relevant professional standards. Although Mr D might not have survived even if he had been properly assessed, an opportunity to treat him was lost that might have led to his survival.  All this caused unnecessary distress for Mr D’s family, and was made worse by the way the GP out-of-hours service dealt with the family’s complaint. 

In the words of Mr D’s mother: ‘I feel that if he was treated properly and given the proper medication he would still be alive today to enjoy his life with his parents, his partner and his young daughter’.

What happened next 

We recommended that the out-of-hours service apologise to Mr D’s mother and pay her compensation. We also asked them how they would ensure that they and the GPs had learnt lessons from Mr D’s case, and how they would prevent a recurrence. The service complied with our recommendations. The GPs reflected on the limitations of telephone consultations and how to get the best information available during a telephone consultation, the importance of repeating specific questions to assess the severity of a patient’s condition, and the need to make it very clear when they feel that a face-to-face consultation is necessary, even when it is not convenient. The service made changes to their complaint handling process.  

Summary of failings against standards

Clinical care

Timely history and examination on admission or referral.
Investigations to determine:
  • Indices of perfusion
  • Indices of infection
  • Source of infection
  • Cultures of blood and other sites.
Accurate recognition of the severity of the illness.
All of this to commence immediately on recognition of severe sepsis and to be completed within six hours of presentation.

 

Mr E’s story 

Mr E, a 75‑year‑old man, was in good health and worked part-time. His family described him as a loving husband, father and grandfather, ‘full of life and vitality’. He died ten days after being admitted to hospital, but with the right care and treatment he would probably have survived.

What happened

Mr E had been feeling increasingly unwell for a few days. On 18 January he was taken to hospital.  He arrived at 2.17pm and was seen by a nurse. He had a very high temperature, very rapid pulse, and was breathing quickly. The nurse prioritised him to be seen by a doctor within one hour, but there was a delay of four hours. In the meantime, his condition was deteriorating, and blood tests showed he had a very low white blood cell count.  

At 6.30pm Mr E saw a junior doctor for the first time, in the medical assessment unit. The doctor diagnosed pneumonia and neutropenic sepsis.  Antibiotics and intravenous fluids were prescribed at 7.30pm, but were not administered to Mr E for another two hours. Nursing records show that Mr E was increasingly confused and agitated during the night, but no observations were written down.  

At 10am the next morning Mr E had a cardiac arrest. He was resuscitated and moved to intensive care, where he received full life support and was put on a ventilator.  He remained stable but it was not possible to take him off the ventilator.  On 28 January the central vein intravenous line was replaced, and shortly afterwards Mr E collapsed again and this time could not be resuscitated. 

Mr E’s family described his death as ‘unexpected, premature and devastating for the whole family … Another family must never again experience what we have. This would be a fitting legacy’.

What we found 

We found that it was more likely than not that Mr E would have survived if he had been given the proper treatment. Instead, he was not treated as an urgent enough case when he arrived at the hospital, in spite of his abnormal vital signs, and further checks were not frequent enough. He was not seen quickly enough by a doctor, and there were delays in him being given the prescribed fluids and antibiotics.  We also found that it was possible that Mr E’s final cardiac arrest was precipitated by the insertion of a new central line – a procedure which was poorly documented. As for the Trust’s response to the family’s complaint, they failed to acknowledge all of the failings in care, and took no specific actions to improve and learn from the case.

In severe sepsis the doctor should not leave the patient until antibiotics have been administered.’
Royal College of Physicians

What happened next

Following our investigation, the Trust apologised to Mr E’s family and paid them compensation. They also reported on the lessons learnt from Mr E’s case, and the remedial actions they were taking. Key points included: improved staff training and supervision; changes to the early warning score system; a policy for medical review before patients leave the emergency department; increased staffing levels; and enhanced clinical leadership.

What happened next

Following our investigation, the Trust apologised to Mr E’s family and paid them compensation. They also reported on the lessons learnt from Mr E’s case, and the remedial actions they were taking. Key points included: improved staff training and supervision; changes to the early warning score system; a policy for medical review before patients leave the emergency department; increased staffing levels; and enhanced clinical leadership.

Summary of failings against standards

Clinical care

Timely history and examination on admission or referral.
Investigations to determine:
  • Indices of perfusion
  • Indices of infection
  • Source of infection
  • Cultures of blood and other sites.
Basic resuscitation with: 
  • Large volume fluid therapy
  • Intravenous broad-spectrum antibiotics after taking cultures
  • Vasopressor therapy if required to maintain adequate haemodynamics and tissue perfusion.
All of this to commence immediately on recognition of severe sepsis and to be completed within six hours of presentation.

Organisation of care

Appropriate and timely senior medical input.
Timely referral to critical care.

 

Mrs G’s story 

Mrs G was 67 and in reasonable health. Her husband had retired and they were looking forward to their time together. Mrs G died of severe sepsis within 24 hours of being referred to hospital with flu-like symptoms. The outcome might have been different if staff had recognised the signs more quickly.

What happened

One Friday Mrs G came home from her job as a supermarket cashier feeling unwell. She took paracetamol and rested over the weekend. On Monday her work colleagues told Mrs G that she ‘looked awful’, but she refused to go home early.  Mr G said his wife ‘did not like being fussed over’. She saw a GP that evening and again the next morning, complaining of a swollen neck and flu-like symptoms. The GP referred Mrs G to hospital. 

Mrs G arrived at the hospital at 11am. She saw a junior doctor from the ear, nose and throat department at 11.40am, who diagnosed a neck abscess and took advice from a registrar before deciding what should happen next. Mrs G was admitted for a full investigation, and so that the abscess could be drained. At 1.30pm an intravenous drip was inserted. Antibiotics were prescribed but they were not given to Mrs G until around 3.30pm.

By 3pm Mrs G’s temperature was high.  She was breathing rapidly, her oxygen levels were reduced, and blood tests showed evidence of infection and acute kidney failure. The junior doctor contacted another senior ear, nose and throat doctor, who advised continuing with the current treatment. The junior doctor was called back at 7.30pm because Mrs G’s blood pressure had dropped significantly.  There was uncertainty about whether she was suffering from severe sepsis or heart failure.  Further tests were done and staff spoke to the medical registrar by telephone. The medical registrar advised them not to change Mrs G’s treatment. 

High risk patients should be discussed with the consultant within four hours if they are not responding as expected.’  
Royal College of Surgeons

By 9.15pm Mrs G was increasingly breathless and the medical registrar was called again. She considered swine flu as a possible diagnosis and arranged yet more tests. The on-call junior doctor checked on Mrs G at midnight. Her temperature was normal but her blood pressure was critically low. At this point, staff considered moving Mrs G to intensive care, but the intensive care registrar said ‘no’ to this. Mrs G was now so breathless that she could not speak and her blood oxygen levels fell, despite staff giving her added oxygen. At 2.20am Mrs G collapsed. Staff resuscitated her, but she collapsed again and sadly died at 3.30am. The cause of death was recorded as sepsis arising as a consequence of a neck abscess. 

Reflecting on events, Mr G said that his wife’s death had come ‘completely out of the blue’ and had ‘totally changed his life’. By complaining about her care and treatment, Mr G hoped that lessons would be learnt and that others would not have to go through the same experience. 

What we found 

The survival rate for patients with such rapidly progressive sepsis is low, even with good treatment. Nevertheless, opportunities to give Mrs G a chance of surviving were missed. The medical registrar’s and the intensive care registrar’s assessments and treatment fell far short of what was required. Other failings included the delay in diagnosing severe sepsis, delays in administering intravenous fluids, the prescription of inadequate amounts of fluids, delays in administering antibiotics, the lack of any consultant-level involvement and the inadequate supervision of the junior doctor.  

What happened next

In line with our recommendations, the Trust apologised to Mr G and paid him compensation. They also accepted that Mrs G should have been looked after in intensive care. The Trust drew up plans to prevent the same failings happening again. They increased staffing for the critical care outreach team and established a ‘hospital at night’ team to provide better care out-of-hours.  They also set out steps to improve the management of severe sepsis, including the introduction of a sepsis box to ensure that antibiotics are available immediately, and a pro forma to document sepsis treatment. Severe sepsis simulation sessions will also be included in an education programme for junior doctors and nurses. 

Summary of failings against standards

Clinical care

Investigations to determine:
  • Indices of perfusion.
Accurate recognition of the severity of the illness.
Basic resuscitation with: 
  • Large volume fluid therapy
  • Intravenous broad-spectrum antibiotics after taking cultures
  • Vasopressor therapy if required to maintain adequate haemodynamics and tissue perfusion.
All of this to commence immediately on recognition of severe sepsis and to be completed within six hours of presentation.
Source control to be performed as soon as possible after initial resuscitation.

Organisation of care

Appropriate and timely senior medical input.
Timely referral to critical care.

 

Mr C’s story

Mr C, aged 63, was having advanced lung cancer treatment, which put him at high risk of infection. Yet hospital staff paid too little attention to this, even when blood tests indicated that he had an infection.

What happened

Mr C began receiving palliative chemotherapy on 12 September.  He was admitted to hospital on 16 September feeling generally unwell and breathless.  He had no fever, but his blood pressure was low and he had a very rapid abnormal heart rhythm. Blood tests showed a low white blood cell count.  He was given medical treatment to control his abnormal heart rhythm.  

On 17 September Mr C saw a consultant, who thought the breathlessness was caused by his abnormal heart beat.  The next day, blood tests showed evidence of infection.  Mr C seemed a little better and it was decided to defer the next chemotherapy dose.  

On 19 September he had no fever but his blood pressure remained low, so further treatment for his heart was considered, but not given. On 21 September Mr C’s condition deteriorated, with low oxygen levels in the blood. He was seen by the intensive care outreach team, who suspected sepsis and planned to give him antibiotics if he developed a temperature.  On 22 September Mr C’s temperature was high, his white blood cell count was lower, and he had increased inflammation.  He was diagnosed with neutropenic sepsis and was given antibiotics, but he continued to decline and sadly died later that day.  

What we found 

More consideration should have been given to the fact that Mr C was at greater risk of infection because of his cancer and its treatment, and more attention should have been paid to the abnormal blood test results.  The Trust did not follow their own policy on neutropenic sepsis, which stated that patients in septic shock (unwell with low blood pressure) might not have fever but still need intravenous antibiotics.
There was also a delay in giving Mr C necessary antibiotics. While Mr C was gravely ill and might not have survived even with good treatment, an opportunity was lost that might have led him to live longer.  

What happened next

The Trust complied with our recommendations. They apologised to Mr C’s wife, paid her compensation, and drew up plans to ensure that their failings were not repeated. Their plans included implementing the sepsis care bundles, improving the recognition of sepsis and monitoring compliance with the sepsis care bundles, and appointing additional staff. 

Summary of failings against standards

Clinical care

Timely history and examination on admission or referral.
Investigations to determine:
  • Source of infection
  • Cultures of blood and other sites.
Accurate recognition of the severity of the illness.
Basic resuscitation with: 
  • Intravenous broad-spectrum antibiotics after taking cultures.

Organisation of care

Timely referral to critical care.

 

Mrs K’s story 

Mrs K was referred to hospital by her GP after her leg had become swollen following a knee replacement operation. There were delays in diagnosing and treating the infection and sadly Mrs K died of sepsis the next day. 

What happened

Mrs K was 71 years old. She had long-standing leukaemia, for which she received regular blood transfusions. Her right knee had been replaced four months earlier, and had then become infected.  On 25 February her GP referred Mrs K to hospital because she was short of breath. Her right leg was also swollen and the knee was tender. Mrs K was also due to have a blood transfusion the next day and was very anaemic.  She was on antibiotics because she had discomfort passing urine and her abdomen was tender. 

Hospital blood tests showed high levels of inflammation, and urine tests indicated an infection.  The provisional diagnosis was that Mrs K’s knee joint was infected, and she was admitted under the care of the medical team.  An orthopaedic junior doctor tried unsuccessfully to take a fluid sample from Mrs K’s knee.  

Although medical notes indicated plans to give her intravenous antibiotics, these were not given. The next day, Mrs K was seen by the medical consultant, who remained concerned that her knee joint might be infected, and passed her care to the orthopaedic team.  The orthopaedic consultant noted the painful knee but suspected a urinary infection.  

The medical consultant saw Mrs K again at 10am the next morning, and remained concerned about a knee infection and spoke to the orthopaedic team.  Mrs K was given intravenous antibiotics and the orthopaedic doctor managed to obtain a sample of fluid from her knee, which showed infection.  By 2.25pm Mrs K was acutely unwell. She was moved to intensive care at 5.30pm, given a blood transfusion, and put on a ventilator.  Her husband visited her during the day and ‘knew she had passed the point of no return’. Sadly, he was proved right. Mrs K died late the same evening. 

Mrs K’s husband felt strongly that: ‘I do not believe that another family should have to experience the great distress … that we have experienced … My hope is that the Trust can learn from this investigation, so that new procedures will be implemented to reduce the likelihood of such mistakes happening in the future.’ 

What we found 

The Trust’s failure to properly assess Mrs K’s medical needs delayed the diagnosis of her infected knee joint. They did not give her antibiotics, and a necessary blood transfusion was delayed.  We also found shortcomings in communication between departments, in record keeping, general care, and in communication with Mrs K’s family. 

What happened next

We asked the Trust to apologise to Mrs K’s daughter, pay her compensation, and draw up plans to prevent a repeat of their failings. The Trust did so. They also undertook a serious incident enquiry, and a trauma services review, which led to a new policy for the clinical treatment of swollen painful knees, and for the appropriate use of antibiotics.  Actions to address the shortcomings in general care included audits on observations and early warning score performance, and monitoring the standards of care. 

Summary of failings against standards

Clinical care

Investigations to determine:
  • Source of infection.
Accurate recognition of the severity of the illness.
Basic resuscitation with: 
  • Large-volume fluid therapy
  • Intravenous broad-spectrum antibiotics after taking cultures.
All of this to commence immediately on recognition of severe sepsis and to be completed within six hours of presentation.
Source control to be performed as soon as possible after initial resuscitation.

Organisation of care

Appropriate and timely senior medical input.

 

Mrs A’s story 

Mrs A died the day after she was admitted to hospital with kidney pain.  Our investigation revealed delays in recognising that she had a kidney infection, and a lack of senior medical staff involvement at an early stage. Matters were not helped by a substantial delay in starting antibiotics. 

What happened

Mrs A, aged 63, had a history of kidney stones and had recently been treated by her GP for a urinary infection.  On 1 November she developed severe pain over her right kidney, and was admitted to hospital. A urine sample was taken and a urine analysis report was recorded. Mrs A was transferred to a second hospital later that afternoon, where the urine analysis report was presented to medical staff.  Observations were satisfactory, and there were no findings apart from tenderness over the kidney.  The surgical team planned a scan the following morning.  

During the night Mrs A’s condition deteriorated rapidly. Her temperature was high (39.80C) and her blood pressure was low.  At 1.30am a junior doctor gave Mrs A 500ml of fluid intravenously. The ‘patient at risk’ nurse reviewed her at 2.55am.  By 3.40am Mrs A’s blood pressure had not improved, and she was given 750ml of fluid. Her blood pressure fell further to 73mmHg at 4.15am, and urine tests showed excess white blood cells.  

The junior doctor recognised that Mrs A had septic shock and spoke to the laboratory about appropriate antibiotics, but these were not administered until 7.15am.  At around 6am Mrs A was moved to intensive care. A central venous monitoring line proved difficult to insert.  Mrs A was put on mechanical ventilation and given increasing doses of drugs to support her circulation.  Her husband did not learn of her deterioration until he called the ward at 10am, by which time Mrs A was unconscious.  She continued to decline, and died at 8.45pm on 2 November.  The post mortem showed that Mrs A’s right kidney was infected and that there was generalised sepsis.

In the words of Mrs A’s husband: ‘We can never bring back my wife or the mother of my sons, but something positive must come from this very raw and personal tragedy. Efforts must be made to ensure that no other patient suffers the same consequences as [she] did.’

What we found 

While not all criteria for severe sepsis were present until 3.40am, there were delays in recognising Mrs A’s kidney infection, and involving senior medical staff and intensive care. There was a substantial delay in starting antibiotics.  All these shortcomings breached the severe sepsis guidance. However, it was not possible to say if Mrs A would have survived, had care been appropriate.  We also criticised the failure to tell Mrs A’s husband about her deterioration, which has affected his ability to come to terms with her death.

What happened next

The Trust agreed to apologise to Mr A, to draw up plans to prevent a repeat of their failings, and to update him on progress. Unfortunately, the Trust missed all the target dates for these steps, which added to Mr A’s frustration. The Trust’s plans included implementing a new sepsis care bundle protocol with a one-hour pathway, changing their observation charts, asking medical staff to record the time that medication is prescribed, and further training for junior doctors.

Summary of failings against standards

Clinical care

Basic resuscitation with: 
  • Large-volume fluid therapy
  • Intravenous broad-spectrum antibiotics after taking cultures
  • Vasopressor therapy if required to maintain adequate haemodynamics and tissue perfusion.
All of this to commence immediately on recognition of severe sepsis and to be completed within six hours of presentation.
Source control to be performed as soon as possible after initial resuscitation.

Organisation of care

Adequate education and training of staff.
Appropriate and timely senior medical input.
Timely referral to critical care.

 

Mrs J’s story 

Infrequent monitoring and technical problems with equipment meant that Mrs J went for long periods without the intravenous fluids she was supposed to have. She was also in hospital for three days before she saw a consultant. 

What happened

Mrs J was aged 65. She had been diagnosed with oesophageal cancer in September. She started chemotherapy in October, with curative surgery planned for a later date. Early on 13 November Mrs J was admitted to hospital with increasing vomiting, diarrhoea and weakness. Her temperature was raised (38.20C).  Blood tests showed a low white cell count, evidence of increased inflammation, and impaired kidney function. The working diagnosis was that Mrs J had chemotherapy-induced gastroenteritis, complicated by dehydration and impaired kidney function, with impending sepsis due to complications from chemotherapy. 

An appropriate management plan was drawn up, covering intravenous fluids, further investigations, and the criteria for starting Mrs J on antibiotics. Later that day, Mrs J developed fever and she was given antibiotics.  But for long periods she did not receive the prescribed fluids because of technical difficulties. 

Patients should be assessed regularly during their hospital admission by staff with necessary competence.’
Royal College of Surgeons

On 16 November Mrs J was seen by a consultant for the first time. Consideration was given to inserting a central venous line for fluid management and nutrition purposes.  The next day a venous long line was inserted, but Mrs J’s fluid intake was still less than intended and there were technical problems with the cannula.  On 19 November Mrs J was seen by the consultant oncologist and nurse specialist.  They noted that fluid replacement was not keeping up with the loss from continuing severe diarrhoea, and that Mrs J’s nutrition was still poor. They considered feeding her intravenously. Fluid administration improved but observations continued to be infrequent. On 22 November Mrs J’s condition deteriorated and she was moved to intensive care.  Mrs J developed heart problems that did not respond to treatment, and she died on 28 November.

Mrs J’s daughter told us that Mrs J had been denied a fighting chance to ‘pull through’. She said: ‘My Dad is the worst affected, as he has lost his life companion. Mum did a lot for him and he has been struggling’.  She told us that: ‘Mum would have wanted something to be learned by this and for this not to happen to others’. 

What we found 

We found several shortcomings in the Trust’s care of Mrs J. These included an important failure to administer and properly monitor her fluid intake, delayed senior medical input, poor communications between doctors and nurses, an inappropriate Do Not Attempt Resuscitation decision, and poor record keeping and physiological and nutrition monitoring. However, because of the severity of Mrs J’s underlying disease and her reaction to chemotherapy, we could not say whether she would have survived had these failings not occurred.

What happened next

In line with our recommendations, the Trust apologised to Mrs J’s family and paid them compensation. They also drew up plans to prevent their failings happening again. Actions included: a revised policy on neutropenia, a revised early warning score policy and related training, new guidance for managing difficult venous cannulation, a review of handover arrangements between shifts of on-call doctors, and a staff training programme. 

Summary of failings against standards

Clinical care

Regular physiological monitoring using track and trigger systems.
Accurate recognition of the severity of the illness.
Basic resuscitation with: 
  • Large-volume fluid therapy
  • Vasopressor therapy if required to maintain adequate haemodynamics and tissue perfusion.

Organisation of care

Adequate education and training of staff.
Appropriate and timely senior medical input.
Timely referral to critical care.
Formation and documentation of a management plan.
Handover according to protocol.