Issue 1 – Sepsis recognition, treatment and escalation
17. Mrs A complains there was a delay in the Trust recognising Mr A’s sepsis. She says once the Trust did diagnose sepsis, it then took too long to provide treatment. She says it should have inserted a cannula sooner. She also thinks the nursing staff should have done more about the delays.
18. In its response to the complaint the Trust said it recognised the signs of sepsis straight away, and immediately began treatment with intravenous (into the veins – IV) fluids.
19. The Trust acknowledged there was a delay in taking blood cultures (a blood test used to identify the type of bacteria causing an infection) and this had a knock-on effect on antibiotics starting. It said other sepsis treatment was timely.
Recognition of sepsis
20. The RCP guidance says clinicians should measure a patient’s early warning score (EWS) by carrying out physiological observations on a regular basis. These are checks such as blood pressure, heart rate and temperature. The result of each physiological observation is awarded a score between zero and three and added up to work out the overall EWS.
21. EWSs are designed to allow clinicians to assess, identify and respond to acutely unwell patients. The higher the score is, the more unwell the patient is. A higher score means monitoring should be more frequent and the clinical response should be more urgent.
22. The relevant recommendations in the RCP guidance are:
EWS: 1-4 Frequency of monitoring: At least every four to six hours Clinical response: · Inform registered nurse, who must assess the patient · Registered nurse decides whether increased frequency of monitoring and/or escalation of care is required
EWS: 5 or more Frequency of monitoring: At least hourly Clinical response: · Registered nurse to immediately inform the medical team caring for the patient · Registered nurse to request urgent assessment by a clinician or team with core competencies in the care of acutely ill patients · Provide clinical care in an environment with monitoring facilities · Clinicians should consider sepsis in a patient with the signs of infection (or a high risk of infection) and an EWS of 5 or more.
23. A urology consultant saw Mr A on the regular daily ward round at 11.05am on 20 June. They said he was stable, needed regular blood tests and should continue mobilising with the physiotherapists.
24. At around 12.52pm the nurse looking after Mr A noted he was short of breath and his oxygen saturations (the amount of oxygen in the blood) were low. The nurse gave him some oxygen, and this improved his symptoms. The nurse checked his observations and his EWS was 2.
25. The nurse checked Mr A’s observations again at 2.36pm as he appeared unwell. He was breathing fast, he had a low heart rate and still needed oxygen. The nurse found his EWS was 6. According to the medical records, the nurse escalated Mr A’s high EWS (and suspected sepsis) to the medical team at 2.40pm, four minutes later.
26. Our view is that after Mr A required additional oxygen at 12.52pm, the nurse monitored him at a frequency in line with the RCP guidance. He needed to be monitored every four to six hours, and the nurse reviewed him again in under two hours in response to a change in his condition.
27. Our urology adviser says the EWS of 6 at 2.36pm was the first point there were clinical signs of sepsis. Given this, and the fact Mr A’s EWS was 2 before this, we do not see any evidence the Trust should have suspected sepsis sooner.
28. Once the nurse caring for Mr A noted his deterioration, it took them four minutes to escalate this to the medical team. We consider the nurse’s response was prompt and in accordance with the RCP guidance.
29. We have not seen evidence of a delay in recognising sepsis and find there is no failing here. We do not uphold this part of the complaint, and we hope this offers Mrs A some reassurance about what happened.
Treatment of sepsis
30. The NICE sepsis guidance says management of sepsis should start straight away, and relevant treatments and tests should be completed within one hour of sepsis being suspected.
31. The UK Sepsis Trust has adapted the recommendations from the NICE sepsis guidance into a simple tool called ‘the sepsis six’ that NHS Trusts can use to track and record the treatment that is provided. This tool is widely used, and we can see the Trust used this tool in Mr A’s case.
32. In accordance with the sepsis six, the following actions should be taken within one hour of clinicians being aware that sepsis is suspected or confirmed:
1) Give oxygen to keep blood oxygen saturations above 94%
2) Take blood cultures (a test that checks what type of bacteria are causing an infection)
3) Give IV antibiotics
4) Give IV fluids
5) Check lactate levels (a chemical found in the blood that in high levels is a sign of sepsis)
6) Measure the amount of urine being passed.
33. Sepsis was suspected at 2.40pm, so the Trust should have completed actions 1 to 6 by 3.40pm.
34. The records show us the Trust completed actions 1 and 6 promptly and on time. The nurses were already monitoring Mr A’s urine output, and this continued once sepsis was suspected. Mr A was already on oxygen and the nursing staff continued to monitor his observations to make sure his oxygen saturations were over 94%.
35. A doctor saw Mr A at 3pm and recommended blood cultures, IV antibiotics and fluids, and an arterial blood gas test (a type of blood test that can check lactate levels). These were actions 2, 3, 4 and 5 of the sepsis six.
36. The Trust’s sepsis six document says the Trust took blood cultures at 4.40pm and gave IV antibiotics at 5pm. However, the prescription chart says antibiotics were administered at 5.45pm.
37. According to the sepsis six document, the Trust gave IV fluids at 4pm but other records (the fluid prescription charts and fluid output charts) say they were given at around 5pm.
38. Lastly, the sepsis six document says the Trust took blood gases and measured the lactate levels at 6.15pm.
39. The timing of some of the actions is unclear, but it is clear from the records that the Trust did not complete all six actions within one hour. There were delays in completing actions 2, 3, 4 and 5 of the sepsis six, and the full pathway was not completed for three hours and 35 minutes. There was therefore a two hours and 35 minutes delay in treating sepsis.
40. Mrs A complains there was a delay in the cannula being inserted. A cannula is needed to give IV antibiotics and fluids, so one should be inserted within this hour if not already in place.
41. Our physician adviser explained the time that fluids and antibiotics are given is more important than the time the cannula was inserted, as this is a fundamental part of the sepsis six. It is not clear from the records what time the cannula was inserted. We have instead looked at the timing of IV treatments as part of the sepsis six and we found a delay there, as set out above.
42. We find the Trust’s treatment of Mr A’s sepsis was not in keeping with the NICE sepsis guidance or the sepsis six and this is a failing. We recognise this issue is very important to Mrs A. We consider the impact of this in paragraphs 47 to 54 of the report.
Escalation of delays
43. Mrs A complains the nurses should have done more about the delays in the doctor’s treatment of Mr A’s sepsis. To help with our consideration of whether the nurses should have done more we looked at the level of monitoring Mr A received after sepsis was suspected.
44. The records show the nurses reviewed Mr A at 2.36pm and monitored him closely following this including checks at 4pm, 5.07pm, 5.57pm, 6.18pm and 6.54pm. The doctors saw him at 3pm, 4.40pm, 5.30pm, 6.15pm and 7pm (when the intensive care team took over his care).
45. Our nursing adviser says there is nothing else the nursing staff should have done during this timeframe in terms of escalating his care. As set out in paragraph 29, the nurses promptly escalated the problem to the medical team. Although there were delays in providing sepsis treatment, the nurses had already involved the medical team and ensured Mr A was regularly monitored after this.
46. We consider the level of nursing care was in line with the RCP guidance for people with a EWS of 5 and above (as set out in paragraph 23), and there is no evidence of a failing here. We do not uphold this part of the complaint.
The impact of the failing in sepsis treatment
47. Mrs A feels her husband might have survived if not for the failings in sepsis treatment. In its investigation of the complaint the Trust said the delays did not affect the outcome for Mr A, and he still would have died from sepsis.
48. Sepsis is a serious condition that can be fatal. The UK Sepsis Trust says it has a 20.3% mortality rate. Whilst timely treatment improves chances of survival, factors like age and history of medical problems can make it harder to recover from.
49. One such factor is a history of surgery in the past six weeks. Mr A had an operation six days before he got sepsis and our physician adviser noted it was a difficult and complex procedure.
50. Although Mr A initially did well after the operation, he was at high risk of complications because of the complexity of the surgery and his multiple other health problems. He had diabetes, high blood pressure, heart disease and high cholesterol.
51. This meant Mr A had few reserves within his cardiovascular system to fight any deterioration. Even a small complication had the potential to be a serious problem for him. Our physician adviser also said it is important to consider the speed of the deterioration. In this case when Mr A developed sepsis, his deterioration was rapid and overwhelming.
52. Considering all of this, our physician adviser says it is more likely than not that Mr A would have still unfortunately died, even with earlier administration of the full sepsis six pathway.
53. We therefore find, on the balance of probabilities, the failing we identified above did not have an impact on the sad outcome for Mr A. On that basis we partly uphold this part of the complaint.
54. Although we think the failing had no clinical impact, we recognise it was serious. This is something we will ask the Trust to address in our recommendations section. We know Mrs A was very concerned about this matter, and we hope this gives her the reassurances she was seeking about the impact of the failing on her husband, and that action will be taken to prevent something similar happening in future.
Issue 2 – Contact with Mrs A when Mr A deteriorated
55. Mrs A is unhappy the Trust did not promptly contact her about her husband’s deterioration. She says she lives a considerable distance away from the hospital and would have come in to be with him at this critical time sooner if someone had contacted her sooner.
56. The NICE acute guidance says patients should be given information about their condition when they are transferred, and their family and carers should be involved.
57. The NMC code says information about ongoing care should be shared with family and carers by giving them the information they ‘want or need’. In this case Mrs A needed to know when her husband had deteriorated so she could choose to be with him in a timely manner.
58. Mrs A had been trying to reach her husband that afternoon and called the ward for an update at around 5pm. The ward staff told Mrs A the doctors were with her husband. They did not mention that she should come to the hospital.
59. At 5.07pm the nurses checked Mr A’s observations. It is not clear if this was before or after the nurse spoke to Mrs A. His EWS had increased from 6 to 10. An EWS of 10 is very high and serious.
60. A doctor saw Mr A after this. Their entry in the notes at 5.30pm said Mr A needed to go to intensive care. The critical care outreach team saw Mr A at 6pm. They confirmed he was seriously unwell and urgently needed to see an intensive care doctor.
61. The intensive care doctor saw Mr A at 7pm and decided he should go to intensive care. He went there at 7.30pm.
62. We consider there was a clear rationale for nursing staff to contact Mrs A about her husband’s condition as early as 5.30pm and certainly by 6pm. There was a further opportunity for the Trust to contact Mrs A at 7pm. It did not call her until 8pm after it placed Mr A on a ventilator.
63. In keeping with the NICE guidance, Mrs A should have been made aware of the likely transfer to intensive care. In keeping with the NMC guidance, the Trust should have provided Mrs A with the information she needed to know about Mr A’s condition earlier than it did.
64. Overall, we find the Trust should have contacted Mrs A up to two and half hours sooner than it did. This is a failing. We know this is important to Mrs A and we consider the impact this had on her in paragraphs 73 to 77 of the report.
Issue 3 – Discussion about the DNAR
65. Mrs A complains the Trust did not discuss the DNAR with her. She says the Trust told her Mr A was unlikely to survive, but she was not aware they would not resuscitate him.
66. The resuscitation guidance says clinicians should explain a DNAR decision to the patient and those close to them as soon as possible. The clinician should ‘be open and honest, use clear unambiguous language and check understanding’. The clinician should document the discussion in the patient’s records and include details of who they spoke to and what they said.
67. Our review of the records shows a conversation between Mrs A and the doctors at 12.05am on 21 June. The record says the doctors told Mrs A her husband had rapidly deteriorated and he needed high levels of drugs to keep him alive.
68. The record says Mr A was in a ‘poor condition’ before the surgery on 14 June and was now too weak to fight this episode of deterioration. The doctors told Mrs A her husband was likely to die. There is, however, no reference to resuscitation or a DNAR decision in this record.
69. The Trust completed the DNAR documentation shortly after this conversation. The form says resuscitation would be ‘futile’ and Mr A had shown a poor response to treatment. The form asks if DNAR has been discussed with the patient’s relative or carer. The Trust ticked yes.
70. We have considered whether the Trust acted in line with the resuscitation guidance. The records show us the Trust did tell Mrs A about the seriousness of her husband’s condition and that he was likely going to die. However, it appears the decision about the DNAR was not communicated and documented properly.
71. Although the Trust ticked yes on the form, there is no evidence in the record of the discussion with Mrs A that the Trust told her about the DNAR. If the Trust had discussed this with her in an open and unambiguous way, this should have been reflected in the record of the conversation.
72. Considering the content of the records and Mrs A’s account, we think the Trust’s explanation of the DNAR and its documentation of this fell below the required standard. There is a failing here. We consider the understandable impact this had on Mrs A in paragraphs 73 to 77 of the report.
The impact of the failings to contact Mrs A promptly and discuss the DNAR
73. Mrs A says the Trust’s delay in contacting her meant she was not able to travel to the hospital before her husband became unconscious. She lived an hour away from the hospital. We can see that she could have been there by around 6.30pm or 7pm had the Trust contacted her at the right time.
74. The records show Mr A was fully responsive until 8pm, when he unfortunately became increasingly drowsy and needed to be put on a ventilator. The failure to contact Mrs A promptly meant she sadly lost the opportunity to see her husband and speak to him before he went on the ventilator.
75. With regards to the DNAR discussion, Mrs A says she knew her husband was unlikely to survive, but she thought the Trust would take all action to save his life. She says the lack of a discussion about the DNAR meant she was unprepared for it, and it was a shock when she found out about it after staff did not resuscitate her husband.
76. We can see how the two failings in communication were a source of distress to Mrs A, and they made an already difficult situation even more challenging. Mrs A says these failings made the grieving process worse, and we think this is understandable. We therefore uphold the complaints about the contact with Mrs A and the DNAR discussion.
77. The Trust has not acknowledged what went wrong with its communication or taken action to put this right. As such, we make recommendations to the Trust to address this.