Failure to investigate and treat Mr Y ’s sepsis
16. The relevant guidance here is NICE guidelines on Suspected Sepsis: recognition, diagnosis and early management.
17. The Trust also has its local guidelines ‘Policy and procedure for the early management of sepsis and septic shock adult patients’ (2020).
18. Our emergency medicine (EM) adviser said Mr Y had clinical signs present that were suggestive of sepsis. According to the ambulance service notes Mr Y was brought in to the Trust’s ED by ambulance on 30 October 2021 with vomiting and shaking and looking grey.
19. Observations recorded at triage gave Mr Y an early warning score of 2. Though not scoring for red flag sepsis (high risk criteria) as indicated in the guidance, there were signs suggestive of amber flag sepsis (moderate risk criteria) on that presentation in the form of shivering, fast heart rate and acute kidney injury (a sudden decline in kidney function).
20. Our EM adviser said the NICE guidelines on suspected sepsis suggested Mr Y had sepsis on this attendance. Therefore, the EM staff should have carried our sepsis screening. This would help to identify if Mr Y had sepsis.
21. The ED doctor initially started Mr Y on intravenous fluids and referred him to the medical team at 8.20pm. Our EM adviser said considering there were clinical signs on attending the ED, sepsis should have been considered and antibiotics administered in line with guidance.
22. The Trust's structured judgement review (SJR) states, 'In ED, there was poor documentation about his bloods with simple statements of ‘raised inflammatory markers and AKI’. There was no thought about starting empirical antibiotics, no diagnosis made, and a plan of IV fluids and medical referral was entirely substandard'.
23. In the circumstances, we find there was a failing in not screening Mr Y for sepsis and managing his care in the ED in line with guidance. We have considered if this had any significant impact on Mr Y .
24. Our physician adviser confirmed that for any unwell patient presenting with clinical features suspicious of infection the question should be asked ‘could this be sepsis’ (NICE Could this be sepsis?). That said, this does not mean that every unwell patient presenting with clinical features suspicious of infection has sepsis. They said this is especially true when a patient has an alternative diagnosis that explains the clinical features. This was the situation here as gastroenteritis was the diagnosis.
25. Our physician adviser said Mr Y ’s key symptom was of diarrhoea with raised inflammatory markers (such as white cell counts and c-reactive protein (CRP) which both go up with infection and inflammation) and acute kidney injury (a sudden worsening of kidney function that can occur for a wide variety of reasons, including dehydration due to vomiting while being on diuretics (drugs that make you pass more urine). With such a combination of clinical feature and investigation results, our physician adviser said it is entirely reasonable to consider gastroenteritis to be the diagnosis, the commonest cause of which is viral infection.
26. Our physician adviser added that national guidelines advise against routinely prescribing antibiotics in people with gastroenteritis (Management Gastroenteritis CKS NICE ‘How should I manage an adult with gastroenteritis in primary care?’). Our physician adviser said the decision had initially been made not to give antibiotics but this was changed on 2 November when Mr Y was not improving.
27. Our physician adviser said if Mr Y ’s temperature had been greater than 38.0 there would have been a more compelling argument to do blood cultures in line with sepsis guidance, though high temperatures are also found in viral illnesses including gastroenteritis, so the high temperature may have been explained by the gastroenteritis. On the whole, our physician adviser said there was little evidence for sepsis, especially in the face of a diagnosis of gastroenteritis that fitted with the clinical picture. Furthermore, we note gastroenteritis was also found on the post-mortem as a contributory cause of death whereas sepsis was not.
28. The Trust did not screen for sepsis in line with guidance. However, whilst Miss X questions if sepsis affected her father’s outcome, there is no evidence to support this.
29. The Trust has offered an explanation on its response dated 11 December 2023 that ‘Sunrise EPR (electronic patient record) system was being implemented in phases and a Sepsis screening tool was not in place at that time. This has since changed and observations outside of set parameters would require a sepsis screening tool to be completed’. Furthermore, it has apologised to Miss X for the suboptimal action.
30. In the circumstances, our decision is there was a failing on the part of the Trust in not following sepsis guidance on Mr Y ’s admission to the ED. However, there is no evidence that Mr Y developed sepsis and this affected his outcome. The Trust has acknowledged that the care provided to Mr Y was suboptimal and apologised to Miss X. It has also indicated changes have been made to its processes. We consider the Trust’s actions are proportionate and no further action is required.
Failure to escalate Mr Y ’s care on 31 October 2021
The relevant guidance is The technology | National Early Warning Score systems that alert to deteriorating adult patients in hospital | Advice | NICE. Under this guidance, a patient is assessed and given a score in relation to clinical observations consisting of respiration rate, oxygen saturation, blood pressure, pulse rate, level of consciousness and temperature.
31. The nurse recorded a NEWS of 5 on 31 October at 6.23pm. According to the guidelines if a patient is scoring a NEWS of 5 or more, the registered nurse responsible for the patient should; • Immediately inform the medical team caring for the patient • Request urgent assessment by a clinician or team with core competencies in the care of acutely unwell adults • Provide clinical care in an environment with monitoring facilities.
32. However, this did not happen. Our view is there was a failing on the part of the Trust in not escalating Mr Y ’s care in line with guidance. We have considered the impact of this.
33. Our physician adviser told us that had the medical team been alerted to review Mr Y when he had a NEWS of 5, they may have assessed him for a source of sepsis, (even though there was little evidence for this). Mr Y ’s NEWS improved such that by the time he was reviewed on the ward round on 1 November at 5.15pm, his observations were better. At that time discussion with the microbiology consultant confirmed that, in the absence of a convincing alternative diagnosis, the suspicion was that Mr Y had viral gastroenteritis. This was confirmed by the post-mortem findings. Our physician adviser said if the medical team had reviewed Mr Y on 31 October when his NEWS was 5 it would have made little if any difference to his situation. His NEWS had improved and his diagnosis at that time was gastroenteritis.
34. In the circumstances, our decision is that there were failings in the nurse not escalating Mr Y ’s care when he had a NEWS of 5. However, there does not appear to any significant impact caused by this failing.
35. We note the Trust acknowledged Mr Y ’s care should have been escalated. It has apologised to Miss X.
36. The Trust also said it provides ‘Early Recognition and Management of Sepsis and Acute Kidney Injury in the Adult Patient’ and ‘Acute Illness Management’ courses, for registered nurses to develop skills in the recognition and management of acutely unwell and deteriorating adults in hospital and staff. We consider these actions are appropriate and proportionate and no further action is required.
Failure to monitor and treat Mr Y ’s calcium and magnesium levels resulting in an electrolyte imbalance
37. Our nursing adviser told us it would be the responsibility of the nurse looking after Mr Y to ensure his observations were done in line with guidance. A patient receiving IV calcium and magnesium should be continuously monitored throughout the infusion Calcium gluconate | Drugs | BNF | NICE Magnesium sulfate | Drugs | BNF | NICE
38. Our nursing adviser said according to the documentation, Mr Y was continuously monitored, however it was not documented on his NEWS chart in line with guidance.
39. The Trust has acknowledged this in its response. It said “regrettably, on review of the observations, it is apparent that although it is documented that Mr Y received continuous monitoring throughout the magnesium infusion he received on 2 November 2021, at 01.45 hrs, the nursing staff failed to document his observations throughout this period. Nursing staff have been reminded of the importance of documenting observations on the EPR “Sunrise” when patients are being continually monitored to ensure there is a record of their observations available to review. Please be assured that following the infusion, bloods were taken to check for efficacy and he was reviewed by the on-call Dr who documented that Mr Y was feeling better and his symptoms were improving.” Our decision is this was a failing.
40. From a medical perspective, there are no accepted national (UK) guidelines for management of hypomagnesemia (low magnesium levels) but the Trust has its own guidelines.
41. Our physician adviser said Mr Y ’s magnesium level was noted to be low on 2 November and the plan was for this to be treated with ‘cautious IV magnesium replacement. The medication charts indicate intravenous magnesium was administered on 2 November as well as oral magnesium.
42. Our physician adviser said Mr Y had heart failure with a weak heart and ischaemic heart disease which is caused by narrowing of the arteries that supply the heart. Although, in practice this is often not an absolute contraindication, our physician adviser said that in such heart patients, intravenous magnesium is best avoided unless absolutely necessary.
43. The records indicate that oral magnesium was given on 1 November before intravenous magnesium was introduced to try and improve the electrolyte imbalance. It is noted that the IV treatment was to be cautious but it seems it had become necessary.
44. The local guideline also says to stop medications that cause hypomagnesemia (low level of magnesium in the blood). This was done as the medication charts show bumetanide (diuretic) and lansoprazole (reduces stomach acid) were stopped.
45. Taking into account our physician’s advice there is no evidence of any significant failings in the Trust’s medical management of Mr Y ’s electrolyte imbalance. There are failings relating to the nursing staff not documenting his observations while he was receiving his infusion. However, there is no evidence this had any impact on Mr Y .
46. The Trust has acknowledged observations were not documented and it has apologised to Miss X for this. The Trust said this issue continues to be addressed by the Trust through shared learning, training and improvements to Sunrise documentation.
47. In the circumstances, our decision is there was a failing on the part of the Trust regarding documentation. However, this had no impact on Mr Y ’s outcome. We consider that the actions of the Trust in providing an apology to Miss Xand making service improvements are proportionate and no further action is required.
Failure to manage Mr Y’s surgical groin wound
48. Miss X complains that the nursing staff failed to manage her father VAC dressing. In accordance with the NICE guidance relating to the ‘Patient experience in adult NHS services’, Mr Y personal cares should have been regularly assessed and managed by the nursing team. This would have included any wound care and tissue viability issues.
49. Our nursing adviser said managing a VAC dressing is an extended nursing skill/role which, according to the Trust, few nurses on the medical wards have. VAC stands for vacuum assisted closure therapy and is also known as negative pressure wound therapy. It is used for acute, chronic or infected wounds to promote wound healing, remove exudate (fluid) and reduce oedema (swelling).
50. The Trust explained that the nurses on the ward did not have the skills to manage VAC dressings. Our nursing adviser told us the nursing team involved were therefore correct in not changing Mr Y ’s dressing if they were not competent in doing so. This is in line with NMC professional standards which say a nurse should recognise and work within the limits of their competence.
51. However, the code also states that an registered nurse should ‘ask for help from a suitably qualified and experienced professional to carry out any action or procedure that is beyond your limits of competence.’ Therefore, the nursing team, upon recognising that they did not have the skills to manage Mr Y ’s wound should have referred him to the tissue viability team. This would have ensured that Mr Y 's wound could be assessed, documented and managed effectively as guidance suggests that Vac dressings should be changed every 48-72 hours (VAC-Therapy-Patient-Information-Booklet.pdf)
52. Our view is this was failing on the part of the Trust in not referring Mr Y . There is no evidence that this failing had any impact on Mr Y ’s sad outcome although we recognise this placed a burden on Miss X. The Trust has acknowledged this in its response and at the meeting, and accepted a referral should have been made to the tissue viability nurse (TVN). It has also apologised to Miss X for this. The Trust also said the nursing team have been reminded of the importance of an early referral to a TVN and a resources folder has also been made available for staff.
53. We have found a failing on the part of the Trust. However, we consider that the Trust’s actions in providing an appropriate apology and making service improvements are appropriate and proportionate and no further action is required.
Communication
54. The relevant guidance that applies here is The GMC Good Medical Practice which states,
‘You must be considerate and compassionate to those close to a patient and be sensitive and responsive in giving them support and information.’
55. Miss X complained about the lack of communication from the Trust about her father’s treatment plan, diagnosis or prognosis.
56. The Trust’s SJR identified there were entries noted by nurses on the ward round entry that the family were raising concerns about their father, but these were not addressed by junior or senior doctors. The SJR said there was a lack of communication about any aspect of Mr Y ’s care when he was moved to the ward.
57. The Trust has apologised that the level of communication the family received about Mr Y ’s treatment fell below expectations. It said it has linked this issue of communication to a strategic objective of the Trust with a view to reducing the number of complaints where communication is a key theme. The Trust also said that learning from this will be shared at the Divisional Governance meeting.
58. Miss X says the lack of communication meant her father died alone without his family with him and this is a significant source of distress to her. We understand that Mr Y passed away unexpectedly early on the morning of 3 November 2021 and there is nothing to indicate that better communication would have changed the situation at that sad time.
59. We have found a failing on the part of the Trust. However, we consider that the Trust’s actions in providing an appropriate apology and making service improvements are appropriate and no further action is required.
Conclusion
60. Having considered the available evidence, we have identified failings on the part of the Trust. The Trust has acknowledged and apologised for the failings and taken appropriate action to address them. It is for this reason we do not uphold the complaint. We recognise the loss of Mr Y has devastated Miss X and her family and we certainly do not wish to detract from that. We hope that we have clearly explained how we have reached our decision to not uphold the complaint.