Sepsis
14. To understand what should have happened during Mr M’s diagnosis and treatment for sepsis, our adviser referred us to NICE sepsis guidance, visual summary and NICE guideline, Suspected sepsis: recognition, diagnosis and early management. The NICE guideline says to use National Ealy Warning Score (NEWS) (a tool used to assess the degree of illness of a patient) to assess people with suspected sepsis. A NEWS score of seven or more means a patient is at high risk and a NEWS of five or six means moderate risk. It says to arrange a review by a senior clinician, carry out blood tests, and if the patient is a high risk, give intravenous (IV) antibiotics within one hour.
15. Our adviser helped us to understand that infections are commonly diagnosed in hospital, but not all lead to sepsis (which is the body’s response to the infection).
16. The Trust diagnosed Mr M with a urinary tract infection on the 9 May, aspiration pneumonia on 15 May and treated him with IV antibiotics.
17. A doctor assessed Mr M on 5 June. His heart rate was high and oxygen saturation low. Mr A’s NEWS score was nine at 7.40pm and eight at 8.10pm. The Trust considered a diagnosis of sepsis and requested a senior doctor review. The doctor took a blood test, and a chest X-ray raised the possibility of pulmonary edema (fluid overload in the lung). The doctor gave Mr M IV antibiotics and a medication to reduce the excess fluid. Mr M’s NEWS score reduced, and his condition stabilised until 11 June.
18. On 11 June Mr M developed a fever, and his NEWS scores were ten and 12. A registrar (senior doctor) considered a diagnosis of sepsis and gave him IV fluids and antibiotics straightaway. The doctor used the first broad spectrum antibiotic used for sepsis. Mr M’s NEWS scores reduced to zero on 12 June.
19. A doctor reviewed Mr M on 13 June at 5.40am because his NEWS scores increased to six and seven. The doctor took blood tests, carried out a bedside chest X-ray and was considering changing the IV antibiotics. Nursing staff continued to check on Mr M, followed by a doctor at 6.10am and a registrar at 7.38am, when he sadly died.
20. We understand it must have been concerning for Miss M, knowing her father had sepsis and wondering whether the Trust treated this correctly. Once the Trust knew of Mr M’s sepsis risk, a senior doctor reviewed him, and gave him IV fluids and antibiotics in line with NICE guidelines. We hope our explanation assures her that there is no indication the Trust did not treat her father correctly. We understand it must be deeply distressing that the treatment given did not work.
Communication
21. Miss M said the Trust did not inform her or her family that it had diagnosed her father with sepsis and that her father’s condition was deteriorating prior to his death on 13 June.
22. To understand what should have happened around communication, our adviser referred us to GMC, Good medical practice which refers to communication. It says, ‘you [doctors] must be considerate to those close to the patient and be sensitive and responsive in giving them information and support’.
23. The NMC, The Code says nurses should ‘share with people, their families and carers, as far as the law allows, the information they want or need to know about their health, care and ongoing treatment sensitively and in a way they can understand’.
24. We first looked at the communication around sepsis. The medical records show a doctor spoke to Miss M on 11 June and explained her father was very unwell, he had a high NEWS score, low blood pressure, high heart rate and a temperature. Miss M raised concerns about earlier explanations of pneumonia, chest infection and aspiration. The doctor explained these all meant the same condition and went onto say that sepsis is when someone is very unwell with an infection.
25. Another doctor provided an update about Mr M’s condition to both his daughters on 12 June at 4pm. The doctor explained his measurements were extremely worrying the day before and could be a ‘flare of the infection’ but he seemed more settled that day.
26. During its local resolution meeting with Miss M, the Trust accepted it did not do enough to tell the family what was happening during their father’s care. It said it could have provided better explanations.
27. We understand it must have been concerning knowing her father had sepsis and not understanding the extent of his condition at the time. The medical records show the doctor explained the sepsis diagnosis on 11 June. There appears to be an opportunity for the doctor to explain this more clearly on 12 June. We appreciate medical terminology can be very confusing. We consider a further explanation would have helped Miss M have a better understanding of her father’s diagnosis and the impact it may have. There is an indication the Trust’s communication was not in line with GMC, Good medical practice and NMC, The Code. We have considered the impact of this further on in this statement.
28. We then considered the communication around Mr M’s deterioration. Miss M said the Trust did not inform her that her father’s condition was deteriorating prior to his death on 13 June. Mr M had a high NEWS score of six at 5.40am. A doctor saw him at 6.10am and a registrar saw him at 7.38am, at which point Mr M sadly died. The Trust telephoned Miss M at 8am to inform her.
29. The medical records say there was a rapid deterioration and there was little opportunity to inform the family. The doctor told Miss M that the time from deterioration to death was very fast, and the medical team were discussing his care and treatment.
30. During the local resolution meeting, the Trust informed Miss M that her father’s health started to decline at 5.40am. It said the medical staff should have contacted her straightaway and its failure to do so resulted Miss M and her sister losing the opportunity to see their father and say goodbye.
31. We understand this must be deeply concerning and distressing. There is an indication the Trust’s communication was not in line with GMC, Good medical practice and NMC, The Code. There was an opportunity for the Trust to have informed Miss M about her father’s deterioration shortly after 5.40am. Given the quick deterioration, we will never know whether Miss M and her sister would have been able to get to the hospital before he died, but they lost the opportunity to try.
32. When the Trust met with Miss M, it apologised and said it intended to share information with medical staff and nurses to ensure this is not the experience for other families.
33. The Trust sent us a copy of the action plan it prepared. It has shared learning with medical staff and nurses to contact families when a patient is deteriorating and to review medical records to provide family updates. It is encouraging staff to listen to families and provide better explanations of medical terms. The Trust now has a sepsis policy and end of life policy which provides information about its process for better communication.
34. Miss M told us she seeks an apology, acknowledgement and service improvements. Our Principles for Remedy say public bodies should acknowledge failures, apologise, make amends, and use the opportunity to improve their services. Our NHS Complaints Standards say organisations should offer fair remedies to put things right and identify learning and use it to improve services. When an organisation investigates a complaint, it should ‘explain why things went wrong and identify suitable ways to put things right for people. It should give meaningful and sincere apologies and explanations that openly reflect the impact on the people concerned’.
35. We understand the poor communication has caused further distress and upset to Miss M and her sister, at a time which was already extremely difficult. We have listened to the recording of the resolution meeting. The Trust empathised with Miss M and her sister, apologised and acknowledged where it went wrong and the impact this caused. It has also taken positive action to learn lessons from what happened. Miss M has been able to achieve the outcomes she is seeking through her own complaint, and therefore we do not think it needs to do anything further. We consider these actions are in line with our Principles for Remedy and NHS Complaints Standards..
36. We understand the upset and distress these concerns have caused Miss M and her sister. We are mindful of how important her complaint is to her and the difficult experience she has had. We recognise the Trust cannot change what happened and the distress Miss M experienced. We hope the Trust’s learning can assure her it has learnt lessons and taken steps to improve its service.