Delay and Sepsis
13. Before we decide if we should conduct a detailed investigation of a complaint, we look at whether there are signs the event complained about had a negative effect which the organisation has not put right. Having done so we have found the Trust has already done enough to put right the impact of these events.
14. Mrs L says when Miss H was admitted to hospital, she was left for hours in a corridor and then put in a room where she believes she was left for longer than she should have been. She says the Trust’s incident report found that there had been serious delays in Miss H’s care, and she still does not have answers as to why the delays occurred.
15. Mrs L also believes her aunt died of sepsis and the Trust failed to identify and appropriately treat her aunt for this. She believes her aunt triggered the sepsis pathway within one hour and 15 minutes of admission. She explained her aunt should have been moved to higher observation area and escalated for urgent medical review following this trigger.
16. The Trust explained due to bed pressures and the high volume of patients admitted into the hospital, patients are unfortunately, having to wait longer than expected for a bed to become available. It also acknowledges there were delays in administering medications.
17. It explained on the morning of admission, during Miss H’s observations, her NEWS2 score was high and showed a significantly low blood pressure (BP) and an elevated heart rate; it says considering her presenting complaint, age and frailty, she should have been escalated to the medical team for an early review and transferred to the majors area (the area where the most seriously ill or injured patients are taken after triage for a more thorough assessment and treatment).
18. The Trust explained her initial BP may have been inaccurate, as subsequent observations showed that Miss H’s BP was within the normal range. It also explained there are many different causes of high NEWS2 score other than sepsis.
19. The Trust explained Miss H was initially diagnosed with a pulmonary embolism (PE - a life-threatening condition where a blood clot, usually originating in the legs, travels to the lungs and blocks an artery) and was put on the PE pathway.
20. It explained that she was booked for a CT pulmonary anagram (CTPA - a medical imaging test that uses a CT scanner, an X-ray beam, and a contrast dye to produce detailed images of the blood vessels in the lungs), and this showed she did not have PE.
21. We understand the delays in Miss H’s care, her diagnosis, and treatments must have been deeply worrying and distressing for Mrs L.
22. Our adviser explained on the morning of admission, Miss H’s blood pressure was noted to be low, and this was the reason for a high NEWS2 score, but this was not escalated and explained that not escalating an initial high NEWS2 score is not a good medical practice, in line with RCP, NMC, and GMC guidelines.
23. Upon review of Miss H’s medical records, we can see the following series of delays in her care, which are not in line with the NMC (Paragraph 1.4) which states to ‘make sure that any treatment, assistance or care for which you are responsible is delivered without undue delay’, and the GMC (Paragraph 7c) which states ‘in providing clinical care you must promptly provide (or arrange) suitable advice, investigation or treatment where necessary’:
• Miss H was not seen by a doctor until seven hours after her admission • Miss H received her first form of medications just over nine hours after admission (over two hours after being seen) • In the early hours of the following day, Miss H was still in the ED, in a room on a trolley awaiting to be transferred to the medical assessment unit (MAU).
24. Miss H’s records show that at the time of admission, she was handed over in the emergency care and assessment (ECA) area within the ED. An hour later, her observations were taken, and showed that she had a NEWS2 score of 5.
25. Her records show she was alert and in severe pain. We cannot see that the Trust acted upon this high NEWS2 score, in line with the RCP guidelines, which states that ‘a NEWS2 score of 5 or 6 that is new for the patient’, indicates:
• the patient should be monitored hourly initially • the registered practitioner is to urgently inform a clinician competent in the assessment of acutely ill patients – this will be decided locally and could be the emergency response team (dependent on skill mix), ward doctor etc • assessment is expected within 60 minutes • moving the patient to an environment with monitoring facilities should be considered.
26. We recognise finding out about the prolonged delay in Miss H’s care, combined with the potential seriousness of her condition from the outset, may have been particularly distressing for Mrs L.
27. We next considered Mrs L’s concern about sepsis. She explained that her aunt should have received treatment on the day of admission for sepsis, and sadly died without receiving treatment.
28. Our adviser gave their view that Miss H’s initial low blood pressure reading was likely erroneous, noting that eight hours later, Miss H’s blood pressure had returned to normal and her NEWS2 score was 1, indicating a low risk of sepsis. They further explained that, in cases of genuine sepsis, a patient’s condition would typically deteriorate rapidly without treatment, which did not occur in Miss H’s case on the day of admission.
29. The NICE (paragraph 1.3.1) states to ‘assess temperature, heart rate, respiratory rate, blood pressure, level of consciousness and oxygen saturation in young people and adults with suspected sepsis’.
30. The NICE (paragraph 1.4.2) states to ‘recognise that adults, children and young people aged 12 years and over with suspected sepsis and any of the symptoms or signs below are at high risk of severe illness or death from sepsis:
• respiratory rate of 25 breaths per minute or above • heart rate of 130 beats per minute or above • systolic blood pressure of 90 mmHg or less, or systolic blood pressure more than 40 mmHg below normal.
31. We can see in Miss H’s medical record that her second observation was taken in the late afternoon on the day of admission, this showed that Miss H’s heart rate was 90, respiratory rate was 20, blood pressure was 120/79 and she was alert and oriented.
32. We can also see she had a NEWS2 score of one that same evening. Considering this information, advice received, and information in the NICE guidelines, it appears there is no evidence to support the diagnosis of sepsis on the day of admission.
33. We next considered if the Trust’s actions in considering PE, DVT and CAP as potential diagnosis were in line with guidelines.
34. Our adviser explained that considering Miss H’s full picture (sudden onset shortness of breath, slightly elevated respiratory, swollen [red and tender] right leg, and significantly elevated d-dimer levels [a protein produced when a blood clot is broken down by the body]), it was reasonable to think deep vein thrombosis (DVT – blood clot in a vein, usually in the leg) and blood clot in the lung (PE).
35. Our adviser explained that a management plan was constructed according to these working diagnoses (PE, DVT and CAP) and explained these actions were in line with BTS (1 and 2) guidelines.
36. The BTS (1) states that ‘patients with suspected PE should, where reasonably practical, undergo investigation on the same day of presentation to exclude a diagnosis of PE. An alternative strategy of anticoagulation followed by imaging within 24 hours may be considered in patients with suspected PE.’
37. The BTS (2) states that ‘all patients admitted to hospital with suspected CAP should have a chest radiograph performed as soon as possible to confirm or refute the diagnosis’
38. Upon review of information in Miss H’s records, we can see an hour after admission, her bloods were taken due to a possible DVT. In the afternoon, the results came back showing that her d-dimer level resulted as 2260ng/ml which our adviser explained suggests presence of blood clot or an infection in the body (less than 500ng/ml would indicate a negative result).
39. Following this result, when Miss H was finally seen, the doctor considered that she had a DVT and requested for a CTPA to rule out a PE. In the meantime, we can see Miss H was prescribed an anticoagulant (a medication that prevents blood clots from forming or growing) and antibiotics (medication used to treat or prevent infections caused by bacteria).
40. We can also see that Miss H’s CURB-65 (a clinical prediction and a severity assessment tool for CAP) was scored two, which indicates a moderate risk of CAP. When the CTPA was performed, the results showed no sign of PE, no CPA, and no evidence of chest infection.
41. Our adviser explained it is likely that an infection from the right leg spread, and Miss H developed pneumonia the next day after admission as documented in her death certificate.
42. Considering the available evidence, including the independent advice we received, we can see the Trust acted in line with BTS (1 and 2) guidelines. This is because the records show that it carried out the relevant examinations to diagnose and provide suitable treatments for the symptoms with which Miss H presented.
43. We know that Mrs L believes that Miss H had sepsis and therefore, did not receive the appropriate treatment, and is concerned this contributed to her death. We can understand why Mrs L would think this considering what we have identified to potentially be an erroneous blood pressure reading, which led to a high NEWS2 score.
44. The evidence we have seen does not indicate that Miss H had sepsis on the day of admission and the Trust took steps to treat Miss H’s presenting symptoms.
45. Considering the two indications of failings we have identified, we have next looked at the actions the Trust has taken to put things right. Upon review of the Trust’s serious incident and investigation report, we can see it has provided an explanation to Mrs H for the delays (organisational and clinical pressures), it has apologised for the errors identified and has made the following service improvements:
• any lodged patients will leave ECA within one hour or transferred to the Majors department within thirty minutes should no bed be available followed by escalations to the duty manager. This is to directly support the care of patients who are awaiting an admission bed • implemented an ED Sepsis Task and Finish Group. This focus on the delivery of the Sepsis improvement work in the Emergency Department including education, pathways/bundles, audits, targets/KPIs and awareness • Trust Sepsis Team to provide training within ED • developed and implemented the Digital Sepsis Bundle for ED - this include reviewing how the NEWS scores are recorded and escalated in the digital record (it previously used paper copies) • implemented a 'Safety ED Nurse' to support the recognition of the deteriorating patients and the management of Sepsis • re-reinforced the Trust escalation process which identifies the appropriate clinician to escalate deteriorating patient NEWS score - medical staff have the systems up on screen and this is revisited on board rounds to review the management plan, the doctor and the Charge Nurse have an iPad with the live NEWs scores on to continuously monitor the patients • rapid Assessment and Triage/Streaming doctor at front door to Emergency Care Area - one per day and evening shift • two hourly Board Rounds in ECA • developed the ED Sepsis Quality Improvement Programme which hosts a multi-disciplinary approach to improving the management of high acuity patients within the ED ensuring that they receive appropriate and timely treatment.
46. Our Standards say when it has been identified that something has gone wrong, where possible, organisations should put right the impact the failing has had on the individual. Based on this, we think the Trust has done enough to put right the impact Mrs L has experienced and find the actions of the Trust to be in line with our standards.
47. We recognise Mrs L would like financial compensation and have carefully considered this using our severity of injustice scale (SOI), taken from the remedy guidance above. We do not see anything to indicate the Trust should provide a financial remedy in this case.
48. This is because the impact Mrs L has described (unnecessary pain) sit within level one of our SOI. A level one case typically refers to an injustice (pain) arising from a single incidence, where the effect on the individual is of a short duration (no more than one-two days). We think this describes the injustice Miss H experienced before she was given medication for her pain.
49. We thank Mrs L for bringing her complaint to us. We understand that it must have been very difficult for her to go through the details of her complaint again, and we hope that the independent advice and explanations we have given above provide her with some reassurance about the care Miss H received.