January 2021
• Communication of sepsis
20. Mrs A complains whilst in her January 2021 discharge notes there is a mention of sepsis the Trust did not tell her during her stay. She said the consultants told her they did not know what was wrong with her. The Trust said the ED doctor’s impression of Mrs A was she was suffering from intra-abdominal sepsis with constipation on a background of diverticulitis.
21. Diverticulitis is where small pouches in the colon wall become inflamed and infected, causing abdominal pain and other symptoms. The Trust said the ED doctor had probably not completed all investigations at the time to form an opinion.
22. The ED clerking notes on 27 January 2021 at 3.19pm says, ‘IMP (impression); intraabdominal sepsis with constipation in background diverticulitis’. As mentioned above in the background section, the ED diagnosed Mrs A with sepsis.
23. Our ED adviser says for patients diagnosed with sepsis or suspected sepsis, communication and sharing information is paramount for good patient care, experience, and improved outcomes. They referred to the NICE guideline NG51. Paragraphs 1.19 to 1.21 gives guidance for the importance of communication and information sharing for people with suspected sepsis.
24. They referred to paragraph 1.20.1 which says the ED should ensure it nominates a care team member to give information to families and carers, particularly in emergency situations, such as in the ED. Our ED adviser says the nominated care team member should give regular and timely updates on treatment, care and progress to patients, their families and carers.
25. This should include an explanation that the person has sepsis and what this means and any investigations and the management plan. Our ED adviser referred to paragraph 1.20.3 which says clinicians should give people with sepsis opportunities to ask questions about their diagnosis, treatment options, prognosis and complications.
26. Paragraph 1.20.4 says clinicians should give people with sepsis information about charities and support groups that provide information about sepsis and the causes of it. Our ED adviser referred to paragraph 1.21.1 which says clinicians should also give information at discharge for people assessed with suspected sepsis but not diagnosed with it.
27. It says they should give information about what sepsis is and why it suspected it, tests and investigations done, instructions about which symptoms to monitor, when and how to get medical attention urgently. The Trust did not follow the above NICE guideline NG51.
28. Our ED adviser gave additional information about post-sepsis recovery and support which is available on the UK Sepsis Trust website. The UK Sepsis Trust is a charity organisation which offers face to face support groups available nationally for patients who experienced sepsis.
29. We can see there is no evidence in the records showing the Trust told Mrs A she had sepsis during her hospital admission in January 2021. The Trust diagnosed her with sepsis whilst she was in ED, and the records reflect what the Trust said of the ED doctor’s impression.
30. We recognise the first time Mrs A became aware she had sepsis was from reading her discharge note on 29 January 2021 from her hospital bedside. We consider it must have been shocking and distressing for Mrs A to only discover this at that time.
31. From review of the available evidence, we can see throughout Mrs A’s hospital stay, although it was only for three days, the Trust did not tell Mrs A she had sepsis in line with the above NICE guideline NG51. We consider this is a failing. When we find failings, we next look at the impact. We shall consider this later in this report.
• Follow up for sepsis
32. Mrs A complains she was not given any follow up appointments after her discharge in January 2021 in relation to sepsis. We cannot see the Trust responded about this issue. The Trust’s inpatient discharge summary of 27 January 2021 shows the hospital actions were a follow up appointment in the surgical assessment unit (SAU) on 5 February 2021 and it told Mrs A about this.
33. The general surgery clerking note shows Mrs A attended the SAU appointment on 4 February 2021 for a clinical review, blood tests and she reported feeling well in self but lethargic. The inpatient discharge summary of 4 February 2021 shows it discharged her home and advised the GP to refer her to the gastro team if abdominal problems continued or urology department if urinary tract infections (UTI) continued.
34. Mrs A told us during this follow up appointment the Trust’s surgical team doctor did not mention anything about sepsis or give any advice. She said she mentioned to them she had sepsis at her recent hospital admission, but the doctor just told her to find a doctor who would listen to her.
35. We could see no supporting evidence Mrs A asked any questions about sepsis during that appointment. We could see no evidence the Trust arranged a follow up appointment for sepsis. Our ED adviser observed following Mrs A’s discharge from ED the Trust immediately admitted her to the surgical ward in January 2021.
36. The surgical team discharged her and reviewed her a week later by a doctor from the same team. Our ED adviser says patients do not require a follow up consultant appointment for sepsis. However, they expected the Trust to provide information and raise awareness of possible post-sepsis syndrome as mentioned above at paragraphs 26 to 28 in accordance with the NICE guideline NG51.
37. We reviewed all the available evidence and consider there are no failings. As mentioned above, we consider the Trust should have communicated better to Mrs A by giving her information about her sepsis diagnosis, post-sepsis recovery, charities and support groups to help with this at her January 2021 hospital admission. Therefore, we shall not consider this issue further.
June 2021
• Care and treatment for sepsis
38. Mrs A complains she received inadequate care and treatment when being re-admitted to the Trust’s ED department on 1 June 2021 with the same symptoms as in January 2021. She says in the waiting room, her blood pressure and fever were checked once in the seven-hour period. She also said although she was diagnosed with sepsis on 1 June 2021, no antibiotics were given to her until 2 June 2021.
39. The Trust says it was sorry Mrs A’s experience in ED failed to meet her expectations. It reassured her that treatment was appropriate, and her health, safety and well-being were always at the forefront of her care in the ED. The Trust says it reviewed Mrs A’s medical notes and assured her the diagnosis of sepsis was taken very seriously.
40. It says at diagnosis it administered IV (intravenous) antibiotics along with pain relief and IV fluid within 30 minutes of her arrival, which was the appropriate treatment for her condition. Our ED adviser confirmed they could see Mrs A was admitted to ED on 1 June 2021 at 4.34pm. She was discharged from ED on the same day at 8.24pm.
41. From there the Trust moved her to a short stay ward, outflow space, not in the ED but managed by ED. Our ED adviser says moving patients out of ED before the four-hour target was a regular practice to avoid a breach of the national emergency quality indicators at the time of the events.
42. One of the metrics reported regularly by all NHS trusts was the percentage of patients spending more than four hours in ED. This meant many patients were being moved to other spaces, while they were waiting for a bed to become available on a ward. We can see this was the case for Mrs A.
43. Our ED adviser says sepsis is a common and potentially life-threatening condition. It arises when the body’s response to an infection injures its own tissues and organs. Sepsis can lead to shock, multiple organ failure and death especially if not recognised early and treated promptly.
44. Since 2015 the UK Sepsis Trust collaborated with several organisations to produce operational clinical sepsis screening tools for all ages across a wide range of healthcare settings. The sepsis screening tools are aligned with NICE guideline NG51 and NICE risk stratification tool for the recognition, assessment and early management of sepsis.
45. Our ED adviser says they could see the Trust assessed Mrs A’s risk for serious illness and death from sepsis using the UK Sepsis Trust’s sepsis screening tool for adults. This classed patients into high or moderate risk groups of serious illness or death from sepsis using red and amber flags and is not equivalent to a diagnosis of sepsis.
46. The screening tool was triggered when the National Early Warning Score (NEWS2) score for patients was higher than five and an infection was possible. The NEWS2 score was developed by the Royal College of Physicians in 2012 to standardise the process of recording, scoring and responding to changes in routinely measured physiological parameters in acutely ill patients.
47. The higher the NEWS2 score the worse a patient’s illness, for example, higher heart rate, quick breathing. This shows the patient would be at a high risk of deteriorating with a serious illness which could be more concerning for doctors. The NEWS2 score can be calculated using an online medical calculator called the MDcalc. Using this tool and Mrs A’s medical records, our ED adviser calculated Mrs A’s NEWS2 score of six at the time.
48. They referred to the UK Sepsis Trust’s sepsis screening tool and paragraph 25 of the NICE guideline NG51 which were relevant at the time of the events in June 2021. A moderate risk of serious illness or death from sepsis requires the patient to meet any of the following criteria:
• Relatives concerned about mental status • Acute deterioration in functional ability • Immunosuppressed • Trauma/ surgery/ procedure in last eight weeks • Respiratory rate 21-24 • Systolic BP 91-100 mmHg • Heart rate 91-130 or new dysrhythmia (irregular heartbeats) • Temperature <36°C • Clinical signs of wound infection
49. Our ED adviser says based on the above, they could see Mrs A’s risk of serious illness or death from sepsis was moderate. This was because she met two of the criteria for amber flags as Mrs A’s heart rate was 127 beats per minute and respiratory rate of 22 breaths per minute. We can see this in Mrs A’s medical records on 1 June 2021 at 5.08pm.
50. As Mrs A met two of the above criteria for a moderate level, the NICE risk stratification tool sets out for clinicians to undertake a blood test for the patient, and a clinician review within three hours of meeting two or more moderate criteria for the consideration of antibiotics administration. NHS guidance for antibiotics says antibiotics are used to treat or prevent some types of bacterial infection.
51. Our ED adviser says the Trust followed the appropriate actions in a timely manner in line with the sepsis screening tool, NICE guideline NG51 and NICE risk stratification tool. This is because it undertook a blood test as documented in the records on 1 June 2021 at 4.47pm, a clinician reviewed Mrs A immediately after her arrival in ED and she had antibiotic treatment in less than three hours from deterioration.
52. Mrs A’s complaint says on 2 June 2021 at 2.30am she was taken to a ward when she got antibiotics and treatment. Our ED adviser says from review of Mrs A’s medication administration records, they could see the Trust administered piperacillin tazobactam and amikacin to treat Mrs A’s suspected sepsis.
53. We can see the Trust administered these on 1 June 2021 at 5.36pm and 6pm. Mrs A was concerned the Trust only checked her blood pressure and fever once whilst in the waiting room (outflow space). Our ED adviser added they considered the Trust acted appropriately in assessing and treating Mrs A’s moderate risk level for sepsis. This included checking her blood pressure and temperature.
54. As documented in her discharge records, Mrs A was brought by ambulance to ED on 1 June 2021 at 4.34pm and went straight into the resuscitation (resus) area. The resus area in the ED is where patients with immediately life-threatening illnesses and injuries are managed. The resus team act quickly to keep patients alive. Our ED adviser says they assume there would be continuous monitoring of patients whilst in this area.
55. We do not know how long Mrs A was in the resus area however, our ED adviser could see the Trust assessed and monitored Mrs A regularly from the start of her ED admission and before it admitted her to the gastro ward. They could see from review of the records the Trust undertook Mrs A’s observations on 1 June 2021, at 5.08pm, 8.24pm and 2 June 2021 at 12.20am.
56. They said from review of the records they could see the observations showed Mrs A’s condition was clearly improving and not of a deteriorating trajectory from her time in ED onwards. Mrs A’s temperature of 38 degrees went down to 37 degrees from the start of her observations to when a doctor reviewed her on 2 June 2021.
57. We can see the Trust transferred Mrs A to the gastro ward in the early hours of 2 June 2021 when it documented her temperature was 36.7 degrees. We understand Mrs A felt distressed from her time in ED due to her physical symptoms and she was worried the Trust was not assessing and treating her symptoms quick enough for sepsis.
58. This was considering she had similar symptoms six months prior to this hospital admission. We are pleased to see the Trust assessed and treated Mrs A for her moderate risk of serious illness or death from sepsis as soon as ED admitted her in line with the sepsis screening tool, NICE guideline NG51 and NICE risk stratification tool.
59. The Trust continued to regularly monitor Mrs A’s condition which improved by the early hours of 2 June 2021. Based on this, from review of the available evidence, we see no failings for the Trust’s care and treatment of Mrs A’s diagnosis of sepsis in June 2021. Therefore, we shall not consider this issue further.
• Referral to manage hiatus hernia
60. Mrs A complains the Trust delayed referral to manage her hiatus hernia. A hiatus hernia is when part of the stomach moves into the chest, and it can be a common condition for people over 50 years old. The Trust has not responded about this issue however, internal emails from the consultant reflect on the issue.
61. An email of 19 November 2021 said Mrs A had a CT (computed tomography scan) CAP (scan of chest, abdomen and pelvis) which showed she had a hiatus hernia, and it was reasonable to proceed with an endoscopy to investigate this further.
62. An endoscopy is a procedure that allows clinicians to examine the body’s internal organs by inserting a long, thin tube through a natural opening or small incision. We can see the Trust completed the CT CAP on 10 June 2021. It reported, ‘A hiatus hernia is noted. No other abnormality seen in the chest’.
63. Our gastro adviser referred to the GORD – dyspepsia guidance which says the term ‘dyspepsia’ is used to describe a complex of upper gastrointestinal tract symptoms which are typically present for four or more weeks, including upper abdominal pain or discomfort, heart burn, acid reflux, nausea and/ or vomiting.
64. Our gastro adviser noted on admission to hospital in June 2021 Mrs A reported coffee ground vomiting which may be a sign of upper gastrointestinal haemorrhage. The NHS guidance for dyspepsia says these symptoms can be made worse by a hiatus hernia. The GORD – dyspepsia guidance says GORD is a common cause of dyspepsia.
65. The guidance says it is usually a chronic condition where there is reflux of gastric contents (particularly acid and bile) back into the oesophagus (canal that connects the throat to the stomach), causing predominant symptoms of heartburn and acid regurgitation. We note in both hospital admissions Mrs A presented with recurrent abdominal pain, acid reflux and vomiting which are symptoms of dyspepsia.
66. The GORD – dyspepsia guidance says to offer a full dose of protein pump inhibitor (PPI) for four weeks to aid healing. The NHS guidance for omeprazole medication says it is a PPI medication used to reduce stomach acid and treat conditions of GORD. Our gastro adviser says the Trust treated Mrs A with omeprazole in line with the GORD - dyspepsia guidance.
67. We can see the Trust administered this medication to Mrs A during her hospital stay in June 2021 based on her symptoms which indicated dyspepsia and GORD. From review of the available evidence, we consider the Trust treated Mrs A appropriately with PPI medication in line with the GORD – dyspepsia guidance.
68. Our gastro adviser confirmed Mrs A is noted to have a hiatus hernia on her CT scans in January 2021 and June 2021. They said there were no anatomical (relating to bodily structure) complications on the scans. Therefore, there was no indication to refer for urgent surgical assessment of her hiatus hernia. They said there were also no other acute signs of acute haemorrhage which indicated an emergency endoscopy.
69. Our gastro adviser says as Mrs A was treated for aspiration pneumonia (lung infection caused by inhaling food, liquid, saliva or stomach contents into the lungs causing bacterial infection and inflammation) the risk of having an urgent endoscopy (risk of respiratory compromise and further aspiration) would have outweighed the benefits.
70. The Dyspepsia – unidentified cause guidance says ‘uninvestigated’ dyspepsia describes symptoms in people who have not had an endoscopy. It says to refer a patient for endoscopy or a gastroenterologist, depending on clinical judgement if there are refractory (unmanageable) or recurrent symptoms despite optimal management in primary care. This was the case for Mrs A as the Trust had not completed an endoscopy at the time.
71. The Trust attempted to complete an endoscopy before her admission. The ED clerking note on 1 June 2021 supports this by saying she had an endoscopy last week but started vomiting so it could not be completed. It then noted she was due for another endoscopy on 19 June 2021. This was to investigate her symptoms of reflux and abdominal pain.
72. The gastro nurse handover notes on 6 June 2021 say, ‘At 6am, patient was upset and crying. She verbalised to me that she wants to do her endoscopy here in the hospital not on the 19 June 2021 from another hospital…I apologised on how she felt and her experience. Patient also verbalised she will not eat if her endoscopy will not push through here in QEH (Queen Elizabeth Hospital) and will make a complaint.’
73. Mrs A’s medical records showed she asked the nurse again the next day, 7 June 2021, if she could have the endoscopy procedure at the hospital and they responded by saying they would let the doctors know her wish the next day. She skipped eating, drinking and breakfast that day as she was hoping to have the procedure.
74. We then see the Trust’s plan on her discharge notes says, ‘She will have a repeat OGD at DVH hospital on the 19 June 2021 with a prolonged fasting period.’ An OGD stands for oesophago-gastro duodenoscopy which is also known as an endoscopy.
75. Therefore, we can see she was aware, from the start of her hospital admission, of the Trust’s plan for her was to have an outpatient endoscopy appointment on 19 June 2021, nine days following discharge from hospital. Our gastro adviser says the outpatient endoscopy booked for that date was safe and a reasonable timeline for investigation.
76. They said the follow up endoscopy would have provided an opportunity to review her diagnosis, response to omeprazole, and ongoing treatment plan for her hiatus hernia. Mrs A chose to pursue her care in the private sector despite a follow up plan in place for her.
77. Our adviser says the Trust made every effort to provide appropriate care and treatment in the form of investigations following Mrs A’s discharge from hospital in line with the Dypepsia – unidentified cause guidance. We can see Mrs A was very upset and distressed as she wanted and was eager for it to complete the endoscopy during her hospital stay.
78. In her complaint to the Trust, she said she begged for it to perform an endoscopy during the admission. From review of the available evidence, we consider the Trust appropriately referred Mrs A for an outpatient endoscopy to further investigate and confirm her gastro condition in line with the Dyspepsia – unidentified cause guidance. Therefore, we have seen no failings in this issue and shall not consider it further.
Impact
• Communication of sepsis
79. We found failings in the Trust’s lack of communication of Mrs A’s sepsis diagnosis during her January 2021 hospital admission. Mrs A says as a result she has been left feeling extremely stressed, and she had a genuine fear for her life as sepsis was mentioned but not discussed. She said she felt depressed which affected her relationships and communication with her family members.
80. We can understand learning about a diagnosis, especially sepsis, can be incredibly stressful and upsetting for anyone. We recognise Mrs A would have been shocked and feared for her life when she found out she had sepsis.
81. She would have been frustrated and distressed since she did not fully understand the extent of her diagnosis. We acknowledge this would have affected her level of trust with the Trust and the NHS going forwards. If the Trust told her about her diagnosis before she discovered it herself on the discharge note, it would have reassured her it had done all it could to care for her condition.
82. We understand Mrs A says she was depressed which affected her relationships with her family members. We acknowledge it would have been a frustrating and worrying time for Mrs A receiving her sepsis diagnosis at an already difficult time recovering post hospital discharge.
83. We consider depression can lead to family difficulties but may not be the sole reason. We, therefore, cannot link the single failing of communication to depression affecting relationship with family members.
84. Mrs A told us she was in absolute shock again when the Trust diagnosed her with sepsis again in June 2021. We acknowledge receiving a recurrent diagnosis would have caused shock and stress again even if the Trust had fully informed Mrs A about her first sepsis diagnosis. We have made recommendations to put right the impact of the failing below.