6. From the point staff diagnosed his mother’s biliary sepsis on 26 January 2022, Mr G complains staff delayed her treatment for this condition.
7. He says the delay in her care meant she died.
8. Mr G wants explanations about what happened and the Trust to improve its service to prevent it repeating the failings in his mother’s care.
9. Paramedics brought Mrs G to the Trust’s Emergency Department (ED) during the evening of 17 January 2022. She told staff she had increasing shortness of breath and dizziness when she moved. The Trust’s staff moved her to a ward on 18 January.
10. Staff noticed improvements in her condition over the next few days. They considered her medically fit for discharge on 25 January and during the day on 26 January.
11. Early in the evening on 26 January staff noted Mrs G’s temperature increased. At 6.50pm, they diagnosed her with sepsis.
12. Her condition worsened overnight, and at 6.15am on 27 January she had a vacant episode where she lost consciousness. When staff reviewed her after this event, they considered she was dying. They decided to provide ward-based care focusing on maintaining her comfort.
13. Sadly, Mrs G died later that morning. Staff recorded biliary sepsis as the main cause of her death.
18. In its complaint process, regarding the delay Mr G alleged in staff treating Mrs G’s sepsis, the Trust said it prescribed Mrs G antibiotics at 6.50pm on 26 January 2022 having diagnosed her condition. It said staff also gave her intravenous (IV) fluids to treat her sepsis.
19. Due to her congestive heart failure, staff started giving her fluids at a rate of one litre over eight hours. The Trust said staff needed to consider the effect fluids could have on her heart. For this reason, they planned slow fluid replacement.
20. The Trust said nursing staff later escalated concerns they had about Mrs G’s blood pressure falling, and a doctor reviewed her at 9.50pm.
21. The Trust said her falling blood pressure, and the raised inflammatory markers the doctor saw from blood tests they requested, prompted them to increase the rate of her IV fluids and continue antibiotics. It added the doctor planned liver function tests. If these tests showed her condition did not normalise the next morning, they planned an ultrasound to investigate her abdomen.
22. The Trust acknowledged its doctor asked nurses to fit Mrs G with a urinary catheter to monitor her fluid output. However, nurses delayed fitting one until 5.20am on 27 January.
23. The Trust said her condition worsened and doctors reviewed her again at 6.15am following her vacant episode. Based on their review, doctors also felt they needed to rule out bowel ischemia and they asked surgeons to review her.
24. Surgeons reviewed Mrs G and considered her deterioration could be due to biliary sepsis or bowel ischemia. Staff then decided, due to her existing long-term health conditions and how unwell she was at the time, they would not try and treat her through surgery or admit her to intensive care.
25. The Trust said, between diagnosing Mrs G and this decision, its nursing team should have monitored her NEWS every hour from 8.07pm on 26 January. It acknowledged this did not happen.
Overview on the main relevant guidelines
26. To treat Mrs G’s sepsis once staff diagnosed it (as a patient meeting one or more high risk factors for sepsis – Mrs G was over 75), section 1.6 of NICE Guideline 51 says staff should have:
• given her broad-spectrum antibiotics within one hour • given her IV fluid bolus within one hour at a rate 500ml over less than 15 minutes (due to her blood lactate level (the amount of lactic acid in the blood) being over four millimoles per litre (mmol/L)) • referred her to the intensive care team for a review of her management, including considering the need for central venous access and inotropes and vasopressors (due to her blood lactate level being over four mmol/L) • monitored her continuously.
27. If she failed to respond to initial antibiotics and/or IV fluid resuscitation within one hour, staff should have alerted a consultant so they could review her care. NICE Guideline 51 says a failure to respond is indicated by any of the following:
• systolic blood pressure consistently below 90 millimetres of mercury (mmHg) • reduced level of consciousness despite fluid resuscitation • a respiratory rate over 25 breaths per minute or a new need for mechanical ventilation • blood lactate levels not reducing by more than 20% of the initial value within one hour.
28. We saw staff did not follow all these steps in treating Mrs G’s sepsis. In the next sections of our report, we explain our findings about each step.
Antibiotics
29. Mrs G’s medication charts show staff started giving her piperacillin with tazobactam at 6.55pm on 26 January. Our physician said these are broad-spectrum antibiotics.
30. As Mrs G’s medical records confirm staff diagnosed sepsis at 6.50pm, this shows staff started her on broad-spectrum antibiotics five minutes later. Therefore, the Trust started antibiotics promptly to treat her sepsis in line with NICE Guideline 51.
IV fluids
31. Mrs G’s medical records show staff started IV fluids as the Trust described and as we set out in paragraph 18 and 19. This was just after staff diagnosed her with sepsis.
32. However, the amount of fluid staff gave her is lower than the amount we set out in paragraph 26. Therefore, we saw staff did not give Mrs G enough IV fluids within the timescales recommended in NICE Guideline 51.
33. Our physician said, at a rate of one litre over eight hours, these were merely maintenance fluids rather than the fluid bolus recommended by NICE Guideline 51. Our physician said this meant staff did not give Mrs G the recommended IV fluid resuscitation to address her condition soon after staff diagnosed it.
34. Our physician said Mrs G’s heart failure did not preclude staff commencing fluid resuscitation. They saw staff placed emphasis on her heart failure when considering IV fluids. Staff should have considered other factors, which we explain in more detail below, about why she needed fluid resuscitation.
35. Section 1.4.16 in NICE Guideline 51 says, in stratifying the risk of severe illness in patients with suspected sepsis, staff should interpret their heart rate in the context of their illness. Factors staff should consider include whether the patient’s heart rate response may be affected by medicines such as beta-blockers.
36. Beta-blockers are medicines which slow down the heart. They do this by blocking the action of hormones like adrenaline. Doctors often use beta-blockers to treat heart conditions, including heart failure.
37. Mrs G’s medication charts show staff gave her bisoprolol throughout her admission. In the assessment staff did when they diagnosed her sepsis at 6.50pm, they did not note they were giving her this medication.
38. Our physician said bisoprolol is a beta-blocker, which acts to lower heart rate. They said this can mask a potential sign about how severe someone’s sepsis is. That is, an elevated heart rate which a patient’s NEWS would normally show.
39. NEWS measure a patient’s breathing rate, oxygen saturation level, blood pressure, heart rate, level of consciousness, and temperature. Staff give each parameter a score between zero and three. A score of zero means the parameter is normal. Higher scores indicate the patient is more unwell. For example, a higher temperature or heart rate.
40. Staff add up scores for each parameter to give a total score. If staff are giving a patient supplemental oxygen to maintain their oxygen levels, they should add two to the overall score. A higher overall score means the patient is more unwell and at higher risk of deterioration.
41. When staff diagnosed Mrs G’s sepsis, her medical records show staff recorded NEWS of two. This total score was explained by a raised score only on her temperature.
42. Our physician said staff should have considered how her bisoprolol may have influenced her heart rate (scoring zero at the time) and overall NEWS, and whether her score was falsely low.
43. We also saw, in the assessment at 6.50pm, staff noted Mrs G’s blood lactate level was 8.8mmol/L. Our physician said this was an indicator, despite her relatively low NEWS, about how unwell she was.
44. The Blood Lactate Guidance says lactate is useful in identifying otherwise unrecognised critically ill patients. Staff can use lactate levels to gauge illness severity and plan how they respond.
45. Our physician said the greater the level of blood lactate, the greater the severity of a patient’s condition. They said Mrs G’s blood test showed a significantly elevated blood lactate level which indicated she was developing severe sepsis. They said staff should have considered these lactate levels when deciding on treatment, including how this influenced her requirement for fluid resuscitation.
46. Our physician said the staff who reviewed Mrs G at 6.50pm did not recognise the importance of the factors we have set out. That is, the possibility of falsely low NEWS and her significantly elevated blood lactate level. Our physician said staff did not consider these clinically concerning factors about how unwell Mrs G was in their judgment on treatments like IV fluids.
47. To summarise, Mrs G’s blood lactate level was above the threshold when NICE Guideline 51 says staff should have started fluid resuscitation within one hour at a rate of 500ml over less than 15 minutes. We saw there were factors from NICE Guideline 51 staff did not consider on why she needed these fluids. Staff started IV fluids at a lower rate instead.
48. Therefore, we found staff did not act in line with NICE Guideline 51. They delayed giving Mrs G the fluid treatment this guidance recommends.
49. Our physician also said it is difficult to gauge a patient’s response to fluid resuscitation without fitting them with a urinary catheter. Staff can monitor fluid output through a catheter against the patient’s fluid intake. Therefore, staff should have fitted Mrs G with a urinary catheter when starting her fluids.
50. Her medical records show staff did not fit the catheter until 5.20am on 27 January. This was a delay. It was an important device to fit in the context of doing the regular monitoring NICE Guideline 51 says staff should have done and evaluating the effectiveness of the Trust’s fluid treatment.
Intensive care review
51. Regarding an intensive care review following Mrs G’s sepsis diagnosis, her records show staff consulted intensive treatment unit (ITU) colleagues at 7.25am on 27 January about a transfer to the unit.
52. NICE Guideline 51 recommends staff consider such a referral around the time they diagnose sepsis.
53. Our physician said staff should have considered input and assessment from the intensive care team during the evening of 26 January. They added this certainly should have happened by the time staff reviewed Mrs G again at 9.50pm. As we later set out in paragraph 62 and 63, this assessment showed her condition worsened.
54. Having reviewed this evidence and advice, it shows staff considered an ITU referral later than NICE Guideline 51 recommends. Therefore, this was a delay in staff considering the use of treatments available in the ITU.
Monitoring
55. Given the requirement for continuous monitoring set out in NICE Guideline 51, our physician said staff needed to monitor Mrs G’s NEWS closely after diagnosing her sepsis.
56. NICE Guideline 51’s recommendation about monitoring comes from NICE Guideline 50. Section 1.4 in NICE Guideline 50 recommends staff use the NEWS system to monitor patients, including how frequently to monitor them. It recommends staff defer to the RCOP Guidance.
57. In the section about how frequently staff should monitor a patient’s NEWS, the RCOP Guidance says:
• when staff record overall NEWS of one to four, they should check a patient’s NEWS again in four to six hours • when they record overall NEWS of five or six, or a score of three in a single parameter, they should check a patient’s NEWS again hourly.
58. Mrs G’s NEWS charts show, after diagnosing her sepsis, staff recorded NEWS on 26 January at:
• 8.07pm (NEWS four, blood pressure score three) • 9.11pm (NEWS three, blood pressure score three) • 10.58pm (NEWS six).
59. On 27 January, until staff decided Mrs G was reaching the end of her life, and to provide end of life care, staff recorded NEWS at:
• 12.36am (NEWS five) • 2.17am (NEWS five) • 3.45am (NEWS five) • 5.47am (NEWS two).
60. This shows staff did not monitor Mrs G as frequently as the guidelines we have referred to recommend during this period. Staff should have done this every hour from 8.07pm on 26 January.
61. As the Trust acknowledged (and we set out in paragraph 25), staff did not do this.
The Trust’s review of Mrs G’s initial treatments
62. After starting initial treatments following Mrs G’s sepsis diagnosis, her records show a doctor reviewed her at 9.50pm on 26 January. This was beyond the hour timeframe set out in NICE Guideline 51 (in paragraph 27) when staff should review a patient’s response to the treatments and if they need to escalate the patient’s care.
63. Mrs G’s NEWS charts at 8.07pm showed her blood pressure was below 90mmHg. Her overall NEWS increased to four having been at two at 6.01pm. The doctor noted her reduced blood pressure in their 9.50pm review, and she was becoming confused. They repeated blood tests and found her lactate level had increased to 12.8 mmol/L.
64. They then noted staff should increase her IV fluid rate, and they ordered a catheter to measure her fluid input and output rate. They also asked staff to give her further antibiotics. The doctor did not take any further action to escalate her care. This included seeking an intensive care review.
65. Our physician said Mrs G’s rising NEWS (including falling blood pressure) and blood lactate levels meant staff should have considered escalation in her care. These were factors NICE Guideline 51 highlights (and we set out in paragraph 27) which mean a patient may be becoming more unwell and staff should consider escalation.
66. As we noted in paragraph 50, staff did not fit the catheter the doctor ordered until 5.20am on 27 January. This was an important step to monitor the effectiveness of the IV fluids staff gave Mrs G and whether they needed to increase them.
67. Our physician said, when staff placed the catheter and recorded output of ‘150ml of dark urine’, which showed poor output, this indicated staff should have increased the rate of IV fluids they gave her overnight. Had staff fitted the catheter earlier, they may have been able to see this need earlier and adjust her fluids as part of the regular monitoring they should have had in place.
68. After 9.50pm on 26 January, Mrs G’s records show staff did no further medical reviews until 6.15am on 27 January. Staff called an on-call doctor because she had a vacant episode.
69. Only over the next hour or so did staff consider further measures in her care and involve clinicians from other areas. For example, surgeons and colleagues from the ITU. They considered transferring her to the ITU at 7.25am. This happened later than it should have.
70. The staff who reviewed her considered she had deteriorated, and she would not survive any surgical intervention or intensive care treatment. They felt Mrs G was dying at this point, and they decided to provide ward-based care only to help with her comfort during this process.
71. We saw staff made this decision in line with section 15 of Good Medical Practice. This says, when doctors make decisions about treating patients, they must adequately assess their conditions, taking account of their history (including the symptoms and psychological, spiritual, social, and cultural factors), their views and values; where necessary, examine the patient.
72. Mrs G’s records show staff diagnosed her with bowel ischaemia at 6.15am on 27 January. They noted events earlier in her admission and her sepsis diagnosis. Following her vacant episode, these staff asked about her symptoms just before the event and when she regained consciousness.
73. They performed physical examinations, which included examining her chest and abdomen. They noted the results of blood tests staff had requested overnight, and her most recent scan results. This included a chest X-ray they arranged at 6.42am. They noted her latest NEWS, which included her blood pressure.
74. Based on their assessment, further to her sepsis, they considered Mrs G developed bowel ischaemia.
75. Our physician said the clinical evidence supported this diagnosis. They added they saw no evidence of bowel ischaemia earlier.
76. Our physician said, and we can see this in Mrs G’s NEWS charts, her blood pressure fell significantly from the point staff first diagnosed sepsis. Our physician said this drop in blood pressure caused by her sepsis likely restricted the blood supply to her bowel. Therefore, it became ischaemic.
77. Our physician added Mrs G was very unwell by the morning of 27 January, and, as assessed by staff at the time, she was unlikely to survive intensive care or any surgical intervention. On this basis, the decision staff made on next steps was supported by the evidence they gathered in their assessments.
78. Having reviewed this advice and evidence, we saw the decision staff made on 27 January against escalating Mrs G’s care, including to the ITU, was in line with Good Medical Practice. That said, staff considered this escalation and made this decision too late.
79. To summarise, having considered the evidence and advice, we saw staff did not act in line with NICE Guideline 51 in promptly treating Mrs G’s sepsis after they diagnosed it.
80. While staff started antibiotics quickly, they did not consider factors they should have regarding her needs for IV fluids and provide enough within the timeframes they should have. Staff did not monitor Mrs G and review the effectiveness of her initial treatments when they should. They also delayed considering escalation in her treatment until she was too unwell to benefit from this treatment.
81. We hope we have clearly explained our findings about Mrs G’s treatment. We recognise Mr G has concerns her treatment influenced her chances of survival. Below, we explain our findings about what impact these events had.
Impact
82. We carefully considered whether we can link the failings we saw to the impact Mr G alleged in paragraph two.
83. Our physician said it is difficult to determine whether Mrs G would have survived had staff followed all the recommendations in the guidelines we have referred to.
84. They noted Mrs G had serious existing health conditions, and she was frail. We saw her records show she had atrial fibrillation, chronic obstructive pulmonary disease, hypertension, and obstructive sleep apnoea.
85. Our physician said her conditions and frailty made it less likely the treatment recommended in NICE Guideline 51 would have helped her recover.
86. They added, if staff monitored her response to these treatments more closely, for example, IV fluid resuscitation, they may have considered escalating her care earlier if they saw this did not improve her condition. This may have included an ITU admission.
87. Our physician explained patients receive a greater level of monitoring and medical intervention on such units to help them recover. This includes the use of inotropes and vasopressors (medications to support the circulatory system).
88. Had staff admitted Mrs G for intensive care treatment, our physician said her conditions and frailty were likely to affect her ability to recover. Therefore, it is not possible to know whether she would have survived had she had this care earlier, perhaps from the evening of 26 January, before the irreversible effects of septic shock set in.
89. They also added, because her existing health conditions were likely to affect her ability to recover, staff may have decided against an ITU admission. Our physician said this could have been a valid reason staff decided against such an admission when assessing Mrs G’s suitability for ITU care.
90. Taking account of all this, our physician said staff missed opportunities to provide treatment which may have led to a more favourable outcome for Mrs G.
91. Having considered this advice, we cannot conclude the failings we saw caused Mrs G’s death. It is possible she may still have died had staff treated her in line with guidelines.
92. That said, we consider she lost the opportunity to receive treatment which may have prevented or delayed her death.
93. Unfortunately, given the course of events, we can never know what might have happened and what the outcome may have been for Mrs G. We appreciate our physician said it was difficult to determine whether she may have survived, and they highlighted a range of factors that may have influenced this.
94. We recognise this will leave Mr G with uncertainty on the matter. We recognise this lack of closure about his mother’s death is likely to be distressing, and the main injustice for him stemming from our findings here.
95. We do not underestimate how difficult this will be for him. From paragraph 96, we considered whether the Trust has taken the action we would expect to address this.
Has the Trust addressed the impact?
96. Where we see injustice stemming from failings, we use our Principles for Remedy to determine our approach to securing remedy. However, we should also have regard for the outcome(s) the complainant wants.
97. Mr G wants explanations about what happened and for the Trust to take action to prevent a repeat of mistakes in Mrs G’s care. Our Principles for Remedy also say these are appropriate remedies.
98. Therefore, we looked at whether the Trust has done these things already. Having done so, we saw there is further action the Trust should take. We explain this further below.
99. For the mistakes we saw, we looked at whether the Trust has already attempted to give Mr G explanations about the events when responding to his complaint. Our Principles for Remedy say organisations should try to explain why a failing happened. We begin with Mrs G’s IV fluids.
100. Although we saw staff did not give her the IV fluids they should have, as we set out in paragraphs 18 to 25, the Trust explained why staff gave her the fluids they decided on. The Trust also tried to explain the delay it found in staff fitting the catheter. Having consulted Mrs G’s records and relevant staff (its nursing team), the Trust said it could not conclude why the delay happened.
101. Our Principles of Good Complaint Handling say organisations should give evidencebased explanations and reasons for their decisions. Where appropriate, the members of staff involved should have the opportunity to respond.
102. So, the Trust has already done this regarding Mrs G’s IV fluids. It has also taken appropriate steps to try and explain the delay fitting her catheter. As the Trust has taken these actions, we did not see there is more it can do to explain what happened regarding Mrs G’s fluids and why staff took the actions they did.
103. Regarding the Trust’s consideration about Mrs G going to the ITU for care, and the review staff did of her initial treatment for sepsis, we cannot see there is more the Trust can helpfully add on this. As set out in paragraphs 18 to 25, we saw the Trust explained the reasons for the actions and decisions of its staff.
104. These actions may not be in line with guidelines. That said, like the point we made on IV fluids above, the Trust provided explanations about why staff took these actions. This is in line with our Principles of Good Complaint Handling. Therefore, we did not see it can provide further explanations.
105. The Trust said staff should have monitored Mrs G and checked her NEWS more often, and hourly from 8.07pm on 26 January. It explained the same system we set out in paragraphs 39 to 40 and paragraph 57. It acknowledged staff did not adhere to this.
106. That said, we cannot see the Trust gave any explanation on why the omissions it identified happened. We think an explanation from the Trust on this would help Mr G make sense of this. This is something the Trust is yet to do.
107. So, although the Trust has given some explanations about what happened, there are other explanations it should try to provide. We explain what we are asking the Trust to do so it can address this in the recommendations section at the end of our report.
108. To learn lessons from mistakes, our Principles for Remedy say organisations should revise procedures to prevent the same thing happening again, train or supervise its staff, or do a combination of these things. We did not see the Trust took this kind of action to address any of the failings we saw.
109. It did not explain any action or service changes it planned to avoid repeating the delay it acknowledged fitting Mrs G’s catheter. It said it shared its investigation findings about the frequency in which nursing staff monitored Mrs G. It provided no further details, including how this might have shaped any training or supervisory actions.
110. Regarding the other mistakes we found, the Trust did not identify them during its complaint process. Therefore, we did not see it took action to try and prevent these things happening again. On this basis, we saw there is further work for the Trust to do to improve its service.
1. We recognise Mr G has been through a very difficult time losing his mother. He considers she died very suddenly. He told us this left him with concerns about the standard of care the Trust provided and what staff could have done to prevent her death.
2. We carefully considered Mr G’s concerns. Having done so, we saw staff did not adhere to guidelines and they missed chances to give his mother, Mrs G, prompt treatment.
3. We cannot conclude with any certainty she would have survived if she got this treatment. However, she lost the opportunity to receive treatment which may have prevented or delayed her death.
4. We recognise this leaves Mr G with uncertainty on how his mother’s care influenced her death. We recognise this uncertainty is distressing for him.
5. The Trust has not yet taken all the action it should to address this. Therefore, we have partly upheld Mr G’s complaint. We have made recommendations to the Trust at the end of our report.
111. To prevent recurrence of any failings we see, we should ask an organisation to propose its own solutions to these issues.
112. On this basis, we are recommending the Trust makes an action plan. It should consider what changes or improvements it will make so the failings we found are not repeated. The action plan should explain what the Trust will do, when it will do it and who is responsible for these actions. We ask that the Trust shares its action plan with us, Mr G, the Care Quality Commission and NHS Improvement. It should do this within three months of the date of this report.
113. We note the main guideline we referred to in our consideration about what happened is NICE Guideline 51. We appreciate NICE updated this guideline on 31 January 2024. We reviewed the updated guideline.
114. The recommendations we have referred to from the previous guideline still appear in the updated one (in section 1.7). Therefore, we still consider the improvements we are recommending are relevant, and they may help the Trust comply with current guidelines.
115. We hope we have clearly explained our findings about what happened and why we are making recommendations.
116. We recognise our recommendations do not change what happened, and how difficult Mr G found the events he complained about.
117. We hope our work helps in providing some of the explanations he seeks, and that our recommendations can help with this too. We hope our work provides a basis on which the Trust can learn from what happened, and it can use an action plan to make positive changes, which we appreciate Mr G wants too.