Antibiotics 16. Mrs A complains staff did not give her husband antibiotics as soon as possible when he arrived in the ED on 8 March. She feels this meant his sepsis was not treated properly within the ‘golden hour’, and he lost out on the best chance of survival. The golden hour refers to diagnosing and treating sepsis within the first hour of presentation.
17. A doctor visited Mr A at 5.36pm and prescribed antibiotics at 6.05pm. The Trust explained it could not be certain on the specific time the nurse gave the antibiotics due to difficulty reading the nurse’s writing, but it was likely to be 7.05pm. It confirmed the doctor prescribed the antibiotic within the hour, but not when the nurse gave it.
18. Initial Assessment of ED Patients sets out how staff should assess patients when they arrive in hospital. It says staff should triage patients within 15 minutes of arrival. This involves taking their medical observations, such as temperature and heart rate. An ED doctor should then visit the patient promptly. In line with this, a nurse took Mr A’s clinical observations at 5.21pm. This was eight minutes after he arrived.
19. To understand what the term promptly means in this context, our ED adviser explained in this instance a doctor should have assessed Mr A approximately ten minutes after triage. The assessment should have identified Mr A’s sepsis and then the Trust should have started appropriate treatment.
20. A doctor visited Mr A at 5.30pm, within this ten-minute window, and assessed him by taking his medical history and examining him. The doctor diagnosed Mr A with sepsis and suspected the source of infection was from his skin, as his leg ulcers were red and weeping.
21. BUFALO Sepsis 6 sets out how the Trust should then have managed and treated Mr A.
22. The plan is comprised of: • blood cultures • urine output • fluids • antibiotics • lactate • oxygen.
23. In practice, this means doctors should take a patient’s blood cultures, and measure their urine output and blood lactate. Blood lactate increases when oxygen levels are insufficient. The doctor should also give the patient oxygen, fluid and antibiotics.
24. NICE sepsis guidance say doctors should give intravenous (directly into the vein) fluid to patients with sepsis within one-hour.
25. NICE sepsis guidance also says staff should also give the recommended maximum dose of intravenous antibiotics within one-hour to high-risk patients. These antibiotics should be ‘broad-spectrum’, which means they are effective against a wide range of bacteria. Once the source of infection is confirmed, source specific antibiotics should be given instead.
26. A high-risk patient is someone who meets one or more specific criteria, such as increased rate of breathing or heart rate. This is used to identify people who are more likely to become severely ill or die due to sepsis. Mr A was a high-risk patient.
27. NICE leg ulcer guidance says flucloxacillin is the first-choice antibiotic to use when the patient is severely unwell. Flucloxacillin is a narrow-spectrum antibiotic and well suited to treating skin infections.
28. The doctor took Mr A’s blood cultures and started a fluid balance chart to measure his urine output. They gave Mr A 1l of intravenous fluid at 5.35pm, and another 1l at 7.02pm.
29. The doctor prescribed intravenous flucloxacillin at 6.05pm They also measured Mr A’s blood lactate and oxygen levels, which were normal. A nurse gave the prescribed flucloxacillin to Mr A at 7.05pm, and another dose at 2.35am on 9 March.
30. We have found staff at the Trust triaged and assessed Mr A within the timescales set out in guidance. They promptly diagnosed sepsis and started managing it in line with BUFALO Sepsis 6, as they should have done.
31. We recognise flucloxacillin is not a broad-spectrum antibiotic recommended by the NICE sepsis guidance. Furthermore, the nurse administered antibiotics five-minutes later than the one-hour set out in guidance.
32. It was a reasonable decision to give Mr A flucloxacillin because the suspected source of his sepsis was a skin infection. This is in line with the NICE leg ulcer guidance.
33. We understand Mrs A wanted her husband to have received his antibiotics sooner. We consider the five minutes additional wait was a minimal delay, which did not amount to a failing.
34. In summary, we have found no failings with how the Trust identified and treated Mr A’s sepsis.
35. We recognise Mrs A is left distraught by what happened. We understand the devastating experience she had and know she still finds the events very distressing. We hope our findings reassure her staff responded to her husband’s sepsis as they should have done.
Debridement 36. The Trust explained Mr A’s debridement was originally planned to happen on 9 March but the surgeon delayed the procedure because Mr A was not well enough at the time. It acknowledged there was a delay and explained this was to provide him with the best care possible.
37. Our surgeon adviser explained there is no specific guidance setting out when it is best to perform surgical treatment of severe infections - in this case Mr A’s debridement. An exception to this is when the skin infection is necrotising fasciitis. This is a life-threatening condition and should be treated immediately, as set out on the NHS website at the time.
38. Good Medical Practice sets out that doctors must provide a good standard of care. This means adequately assessing patients and providing prompt and suitable treatment where necessary.
39. On the day of the planned surgery, Mr A’s National Early Warning Score (NEWS - a score to monitor whether someone’s condition is getting worse) was increasing. This showed his condition was worsening. He also had an abnormal heart rhythm (atrial fibrillation), so the surgeon decided to postpone the debridement procedure.
40. The surgical team discussed Mr A’s case with an anaesthetist the following day. The anaesthetist recommended an echocardiogram to get more information about Mr A’s heart function before operating. An echocardiogram uses sound waves to create an image of someone’s heart that shows how well it is working.
41. The echocardiogram showed Mr A’s heart was poor at pumping blood around his body and could fail under general anaesthetic. The Trust considered his condition needed to improve so he had the best chance of recovering from the procedure and the general anaesthetic.
42. Mr A still had an irregular heartbeat on 11 March so staff adjusted his medication and fluid to address this. The debridement then went ahead but was more limited than first planned and the Trust carried out the procedure using a spinal block instead of general anaesthetic. A spinal block numbs the body below the waist and allows the patient to remain awake.
43. Our surgeon adviser explained Mr A’s ulcers needed debridement at some point. This is because dead skin can act as a potential entry site for infection, and the loose tissue can be unpleasant for the patient. Removing the dead tissue can speed up recovery of the wound, and in these circumstances would normally be performed under general anaesthetic.
44. Our surgeon adviser added that in Mr A’s circumstances the debridement does not necessarily need to be done immediately, as it was not necrotising fasciitis. However, sometimes surgical intervention can cause more harm if the patient is not well enough to recover. This was the case in Mr A’s situation.
45. As Mr A was not in a suitable condition for the procedure on 9 March, it was a reasonable decision to postpone it. In doing so, the surgeon adequately assessed Mr A and provided suitable treatment based on this assessment as promptly as possible in line with Good Medical Practice.
46. We acknowledge the concern and upset this has caused Mrs A. We would like to reassure her staff had her husband’s best interests in mind when deciding the timing of the debridement procedure.
Slipped off bed 47. Mrs A complains her husband fell from his hospital bed shortly before he died on 12 March.
48. The Trust’s complaint response explained it looked at the Mr A’s notes but could not find a record of the fall Mrs A was referring to. It spoke to the nurse who was looking after him, but they had no recollection of the events.
49. The Trust’s Falls Prevention Policy defines a fall as, ‘an unintentional or unexpected event resulting in coming to rest on the floor, the ground or an object below knee level.’ It says a post-fall assessment must be done and an assessment proforma added to the patient’s record.
50. National falls guidance says nursing staff and then a doctor should assess someone when they fall. The assessment should focus on any injury the fall might have caused. They should also document the reasons for the fall. In all cases they should also complete an incident form.
51. Section 19 of Good Medical Practice says a doctor’s notes should clearly record their work.
52. The doctor’s record of what happened in Mr A’s notes says: ‘- on assessment - patient slipped off bed - repositioned’.
53. The note recorded his NEWS was 8, that indicated he was at a high-level of clinical risk. The note said he was conscious, and the family had been informed. Mr A died approximately 45 minutes later.
54. Mrs A was not in hospital at the time of the incident and says she only learned about what happened when she read through the notes herself a long time after the event. She says staff did not tell her or her daughter about what happened at the time.
55. Our physician adviser explained if a patient fell, they would expect the doctor to record what the person fell onto, and which part of their body took the impact. Our adviser would also have expected the note to included details of whether the fall injured Mr A.
56. The doctor’s note is ambiguous but crucially does not say Mr A fell onto the floor. There is no documentation of Mr A landing on a specific body part, or which surface he fell onto. Further, there was no assessment from other staff, or investigation of the fall. Additionally, there is no evidence anyone told Mrs A or her family about a fall at the time.
57. It might be there are no detailed notes about a fall because Mr A did not land on the floor. Alternatively, it might be the records are incomplete and staff did not record the fall and report it as they should have done. It remains unclear what a slip from bed means.
58. Given the limited details available we cannot definitively say what happened – even on the balance of probabilities. We cannot say if the care Mr A received at the time amounted to a failing or not. This falls short of Good Medical Practice.
59. Being unable to reach a conclusive view amounts to a failing. We have therefore considered the impact of this on Mrs A.
60. The vague note from the time was the underlying reason Mrs A believes her husband fell from bed. Additionally, the Trust’s complaint response missed an opportunity to provide additional information, like asking the doctor what happened.
61. We have spoken to the Trust and it explained it was not aware of any complaints about similar issues. It added the member of staff responding to the complaint could not find the entry in Mr A’s medical notes at the time. Therefore, although they spoke to the nurse looking after him, they did not speak to the doctor who made the record.
62. Mrs A has told us about the distress she experienced due to her belief Mr A fell. We cannot resolve her concern, and not knowing what happened is an injustice in itself. With this in mind, we have made relevant recommendations to the Trust. These are set out below.
63. We understand Mrs A’s concern given the belief her husband fell from bed. We hope the recommendations provide closure on this exceptionally upsetting source of distress.