Identifying infection
26. Mr I complains staff took too long to identify his wife’s infection. He says blood test results did not come back until after she died.
27. Our physician adviser said whilst there is detailed guidance on identifying sepsis, there is no specific guidance on identifying potential infections.
28. In lieu of specific guidelines, we sometimes refer to GMC’s good medical practice which says doctors must provide a good standard of practice and care. They must adequately assess a patient’s condition and take account of their medical history. Doctors must examine patients and promptly provide or arrange suitable advice, investigations and treatment.
29. Mrs I went into hospital on 20 August following a dizzy spell. She had a history of irregular heartbeat which she was taking medication for. Our adviser said this medication can cause dizziness.
30. Clinical records show staff triaged Mrs I at 10.16am and an emergency department doctor examined her at around 12.50pm. Our adviser said this review was thorough and at this time Mrs Wilson did not appear to have any clear signs of infection. Staff carried out a chest X-ray during the afternoon which came back as normal.
31. A senior doctor reviewed Mrs I at around 9pm. She still had no symptoms of a chest infection but reported passing urine more often which can be a sign of urinary infection. The senior doctor decided to start a broad-spectrum oral antibiotic.
32. Our adviser explained broad-spectrum antibiotics are medications that treat a wide range of bacterial infections which clinicians use when they do not know what specific bacteria is causing an illness. They are often for severe infections or when the specific focus of infection has yet to be defined or before lab results are available.
33. Mrs I did not have any specific signs of infection during the senior doctor review. Clinical records show the senior doctor chose to prescribe antibiotics as a precaution. Our adviser said this was a sensible and cautious decision as it meant Mrs I was already receiving suitable treatment before she began showing specific symptoms of infection.
34. A senior doctor noted Mrs I was showing signs of an infection at around 9am on 21 August. She had developed noisy breathing which can be a sign of chest infection.
35. Mr I considers staff should have identified his wife had an infection sooner than this. We have seen no evidence Mrs I had an infection on 20 August nor did her condition change overnight between 20 and 21 August.
36. We have seen staff promptly identified Mrs I had an infection on the morning of 21 August. Our adviser said clinicians did not miss an opportunity to identify this sooner.
37. We understand Mr I is worried his wife’s blood test results only came back after she died. We are sorry for the distress this caused him.
38. Our adviser said blood test results normally take up to two days to come back. This means it is likely the results would have always come back after Mrs I had sadly died even if she showed signs of infection earlier.
39. We consider staff promptly identified Mrs Wilson was unwell due to an infection on 21 August. This was in line with GMC guidance which says doctors must adequately assess a patient’s condition. We have seen no indication of a failing in this aspect of the complaint.
Treating infection
40. Mr I considers staff delayed treating his wife’s infection and that earlier treatment may have prevented her death.
41. Clinical records show a senior doctor identified Mrs I had signs of sepsis at the same time she showed signs of infection on 21 August.
42. The UK Sepsis Trust says when a patient has an infection, and signs of sepsis doctors should carry out the sepsis six within an hour. This includes: • ensuring a senior clinician attends • starting oxygen if blood oxygen levels are less than 92% • obtaining IV access and take bloods • giving IV antibiotics (maximum dose broad spectrum therapy) • giving IV fluids • monitoring using NEWS2 • measuring urinary output.
43. The records show staff carried out the sepsis six within the recommended timeframe. A senior clinician was already with Mrs I and her oxygen levels were in target, so oxygen was not needed.
44. We can see staff took bloods, changed antibiotics from oral to intravenous and started intravenous fluids. They were already monitoring Mrs I’s observations with NEWS2 and began measuring her urinary output after 9am.
45. Mrs I was already on a broad-spectrum antibiotic at the time her infection became visible. Clinicians use these antibiotics when they do not know the exact source of infection because they treat a wide range of infections.
46. Our adviser noted Mr I’s concern that a lack of blood test results affected his wife’s treatment for infections. They explained the blood test result being available would not have changed the treatment Mrs I received as treatment for sepsis is the same regardless of infection source.
47. We recognise Mrs I’s sudden deterioration came as a shock to her family and understand why they consider staff did not treat her quickly enough. Sadly, sepsis can sometimes be fatal even when it is recognised early and treated promptly.
48. The evidence suggests staff promptly identified Mrs I had an infection that had turned into sepsis. They followed the sepsis six and provided the treatment it recommends in the timeframes it recommends. This was in line with GMC guidance which says doctors must promptly provide suitable treatment. We have seen no indication of failing in this aspect of the complaint.
Nursing care
49. Mr I complains about nursing care staff provided his wife the day she died. He says staff did not monitor her or meet her basic care needs. He says this meant his son had to let staff know she had died. He explains this caused the family distress.
50. The relevant guidance for this aspect of the complaint is NICE guidance on ‘care of dying adults in the last days of life’. This says nurses should keep checking and understanding the wishes of the dying person and those close to them. The guidance makes it clear good end-of-life care includes listening to and taking account of the needs and wishes of both the patient and the people important to them.
51. Clinical records show a doctor recognised Mrs I was dying at around 2.05am on 22 August. They explained this to her family who were distressed and considered she had not been treated quickly enough. The doctor began end-of-life care planning.
52. At 2.21am a nurse spoke with Mrs I’s family and confirmed they understood she would no longer have observations overnight and would not receive antibiotics in the morning.
53. The nurse could not discuss Mrs I’s wishes with her as she was not responsive but noted her family wanted her to remain comfortable and on oxygen. The nurse explained Mrs I could have hourly medication for comfort. There is no record of any further nursing interaction before Mrs I died at 4.55am.
54. Our nursing adviser said some families will want privacy at the end of their loved one’s life. This does not appear to be the case here as the evidence suggests Mrs I’s family expected ongoing nursing input.
55. Our adviser said staff should have visited Mrs I at least once an hour given the families concerns. They said this would have ensured Mrs I was comfortable and would have given nurses the opportunity to provide mouthcare and consider whether she needed symptom relief. This did not happen which means Mrs I did not receive nursing care in line with NICE guidance. We have seen an indication of failing in this aspect of the complaint.
56. Mr I says a lack of nursing care meant his son had to ask for a sponge to moisten his mother’s mouth. Our adviser explained Mrs I’s dry mouth was likely caused by the oxygen she was receiving.
57. It is clear staff missed opportunities to explain this to the family and to offer mouth care without them having to request it. As well as opportunities to provide reassurance and support to Mrs I’s family in her final hours. We recognise this will have caused Mr I and his family distress.
58. Mr I also says his son had to inform staff that his mother had died. Our adviser said it is common for family members to inform staff when a person has died, and this could still have occurred even if staff were carrying out hourly checks. For this reason, we cannot link this specific claimed impact to the indications of failing we have seen.
59. The evidence suggests the Trust’s actions caused Mr I and the family distress for around two hours. We consider after this point their distress was understandably due to the sudden death of a loved one.
60. In its response to the complaint the Trust accepted it did not carry out regular checks. It acknowledged staff should not have left the family feeling unsupported and recognised the distress this caused. We can see it apologised and said it would share the family’s experience with nursing teams to support learning. It also committed to carrying out regular audits of documentation around end-of-life nursing checks.
61. We recognise Mrs I’s rapid deterioration came as a shock to her family. We understand the lack of nursing checks caused additional distress at an already distressing time.
62. We can see the Trust has acknowledged what went wrong, apologised and set out actions to prevent this happening again. In line with our remedy guidance, we are satisfied these actions are proportionate to the injustice Mr I experienced.
63. For these reasons, we will take no further action on this complaint. We understand how upsetting these events have been for Mr I and his family. We hope we have been able to provide some reassurance that we have carefully considered his concerns, and we thank him for bringing this complaint to our office.