Sepsis diagnosis and management
13. Before we decide if we should do a detailed investigation of a complaint, we look at whether there are signs the organisation got something wrong. We do this by comparing what should have happened with what did happen. We have done this and have not seen any signs that something has gone wrong in the way the Trust managed Mrs N’s symptoms.
14. GMC guidance says doctors, ‘must work collaboratively with colleagues, respecting their skills and contributions.’
15. NICE guidance explains the steps for managing and treating sepsis for adults. It says the patient should be reviewed by a senior clinical decision maker, have blood tests taken and be started on a broad-spectrum antibiotic (used to treat a wide range of infections).
16. It also says to regularly monitor a person who meets any high-risk criteria using a track and trigger system (like NEWS 2, a tool to track and score clinical deterioration). The guidance says clinicians must assess the source of infection and personalise investigations to the findings.
17. RCOP guidance says a vital sign monitoring system (like NEWS2) is important in the early recognition of sepsis. It explains a NEWS score of five or higher should raise suspicion and alert an urgent clinical response.
18. Mrs R explains the Trust repeatedly said her mother did not have sepsis.
19. The Trust explained it treated Mrs N’s infection with antibiotics when she arrived. It says this led to Mrs N’s condition improving and it was able to stop antibiotic treatment. It says she quickly declined later in the admission and although it treated her, this did not stop her from dying.
20. The emergency department (ED) triage notes show the clinician recognised Mrs N could have an infection and there were ‘red flags’ for sepsis. These notes also show Mrs N’s observations and NEWS scores were recorded and she started antibiotic treatment (flucloxacillin) within half an hour of triage. Our physician adviser confirmed Mrs N was reviewed by an appropriate senior clinician and the actions they took, and when they took them, were in in line with NICE guidance.
21. Our physician adviser explained due to the skin infection on her hand Mrs N was assessed by a specialist plastic surgery team within a few hours of admission. The team drained and cleaned the abscess. This investigation of the source of Mrs N’s infection seems to be in line with NICE guidance.
22. The plan recorded in the notes included blood cultures (tests) and microbiology testing. In view of the infection, our physician adviser explained the antibiotics were appropriately changed to co-amoxiclav. This is in line with NICE guidance.
23. Our physician adviser reviewed the records made throughout Mrs N’s admission and felt the Trust monitored and managed her as it should have. We can see that Mrs N’s NEWS score was recorded many times each day. Our nursing adviser felt the nursing staff recorded and monitored Mrs N’s observations in line with RCOP guidance.
24. Our physician adviser explained that Mrs N had regular medical reviews during her admission, which was appropriate due to complicating conditions like low sodium levels. They explained the medical team worked well and with the plastics team who were seeing to Mrs N’s hand wound. The records show there were regular assessments from both teams and this is in line with GMC guidance.
25. The records show Mrs N’s NEWS score was recorded as two or below from 16 June and due to this improvement, her antibiotics were stopped on 19 June. This NEWS score shows there was a low clinical risk.
26. Our nursing adviser explained that Mrs N’s NEWS score increased to five (medium risk) on 23 June, and nursing staff escalated this to clinicians in line with RCOP guidance. Our physician adviser says clinicians considered all potential causes of the deterioration in her NEWS score and as sepsis was considered a likely cause, they restarted Mrs N on antibiotics. This seems to be in line with NICE guidance.
27. Mrs N began to quickly deteriorate in July. Our physician adviser felt there were multiple potential contributing factors and the Trust started appropriate treatments. Mrs N was escalated to the ICU, but despite intensive treatment Mrs N died.
28. We can see no signs the Trust failed to monitor Mrs N in line with guidance.
Nutrition and hydration
29. NMC guidance says nurses must show the skills and ability to meet nutrition and hydration needs. It says nurses must help with nutrition and hydration, use assessment tools and record intake to be able to respond to issues.
30. Mrs R says the Trust failed to make sure her mother’s nutrition and fluid intake was good enough. She says her mother ate poorly while in hospital and mainly ate sugary foods like jelly and yoghurts which are not nutritious. She says although her mother was not diabetic, she had a hypoglycaemic episode near the end of her admission because of all the sugar she was eating.
31. She says her mother was very dehydrated during her stay. She explained she noticed her urine was dark brown and she had to tell staff.
32. The Trust says Mrs N had low sodium, low glucose and increased lactate. It suggests Mrs N’s illness contributed to this which led to her confusion and hypoglycaemic episode. It explained there are records to suggest Mrs N was encouraged to drink more fluids.
33. Our nursing adviser explained Mrs N’s nutrition was assessed when she was admitted, using the malnutrition universal screening tool (MUST). She was recorded as high risk and MUST says food charts should have been used to make sure her intake was being monitored. Our adviser explained the first food observation chart was completed a week after admission, indicating she was not being monitored in line with policy.
34. Our nursing adviser felt the charts that were completed showed Mrs N had a very poor food intake throughout her admission. This supports what Mrs R told us about her mother’s diet while in hospital.
35. Mrs N was referred to a dietician on 17 and 24 June and they advised nutritional supplements twice a day. Our nursing adviser could not see any evidence in the records that the nutritional supplements were given to Mrs N. This would not be in line with NMC guidance.
36. Our physician adviser explained Mrs N’s fluid balance was complicated as at different times in her admission she had hyponatremia (low sodium levels) that needed fluid restriction, and dehydration which meant increasing her fluid intake.
37. Our nursing adviser explained that when Mrs N was on fluid restrictions and when she was taking intravenous (IV is when fluids are inserted in the veins) fluids, her intake should have been closely monitored and recorded. They explained that overall, the fluid records were poorly completed and on 20 June they were not completed at all.
38. Our nursing adviser also noted there were some days during fluid restriction where Mrs N had more fluids than advised. For example, on 23 June, she took in 1725ml while on a 1000ml restriction. This suggests Mrs N’s fluid was not managed or recorded in line with NMC guidance.
39. We asked our physician adviser to consider the impact of this on Mrs N. They did not think that poor hydration or nutrition would have affected Mrs N’s deterioration and death. They explained Mrs N’s other issues, like the wound, infection and heart failure were the main factors in her deterioration.
40. Mrs R told us she would like service improvements as an outcome to her complaint.
41. To resolve this part of the complaint, we asked the Trust if it would consider making service improvements to stop these issues happening again. The Trust has confirmed it will do this.
42. We discussed this with Mrs R and she said the failings we found were in line with what she saw while she visited her mother. She said she was happy with the resolution we put to the Trust if it would stop this happening to anyone else in the future.
43. In summary, we have seen signs the Trust did not follow NMC guidance for nutrition and hydration. Although this did not impact on Mrs N’s deterioration, we have agreed with the Trust that it will take action to resolve the complaint. We have asked the Trust to produce an action plan on how it will make service improvements to address what we found.
Communication in the ICU
44. GMC guidance says clinicians must communicate effectively, be considerate to those close to the patient and be sensitive and responsive in giving them information and support.
45. Mrs R says while Mrs N was in the ICU, the family were told to say their goodbyes to her. She was then told by a different clinician that they would be trying more treatment. As her mother died a short time after this, she explained how traumatic this was and how she feels the Trust added to her distress.
46. The Trust apologised for any upset caused and explained this was not its intention. It said the ICU clinicians do everything possible to help the patient recover.
47. Mrs N was transferred to ICU on 10 July. The notes show at around 9pm the Trust had a discussion with Mrs N’s son and explained she ‘might not survive the admission’.
48. On 11 July a Do not attempt cardiopulmonary resuscitation (DNACPR) was agreed with Mrs R and her brother, and Mrs N’s ‘functional decline’ was discussed. The notes show staff discussed the suggested treatment and explained that if there was a negative response, medication would likely be stopped because of the non-reversable underlying problems.
49. Our physician adviser explained patients admitted to the ICU are critically unwell and are there to have intensive medical treatment. They explained usually clinicians will have a conversation with the family to explain that the patient may not get better.
50. Our physician adviser reviewed the communication notes in the records and felt they showed communication was in line with GMC guidance. We understand why clear conversations to prepare the family may have been necessary given Mrs N’s critical condition.
51. We think it was necessary for the Trust to have these difficult conversations with Mrs R and her family. The Trust seems to have communicated that Mrs N was critically unwell but it was trying to give her the best possible chance of recovering. We do understand this may have seemed confusing. We do not think there was a failing in the Trust’s communication.
52. We do not wish to lessen the upset these conversations caused at what was a very difficult time and recognise how much Mrs R was affected by what happened.