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Death of young woman from sepsis was avoidable, Ombudsman finds

A 26-year-old woman’s death from sepsis was avoidable, an investigation by the Parliamentary and Health Service Ombudsman has found.

Staff at Doncaster and Bassetlaw Hospitals NHS Foundation Trust did not diagnose and treat the life-threatening condition quickly enough, and she died as a result. 

The woman’s mother Mrs Katie Hemmings from Doncaster, on behalf of her daughter’s extended family, brought a complaint about the Trust to the Ombudsman after the Trust’s own investigation failed to recognise several serious mistakes in her daughter’s treatment.

Miss Anna Hemmings, who had spina bifida, hydrocephalus and was partially sighted, was admitted to the hospital in October 2015 suffering from a chest infection, a urinary tract infection (UTI) and sepsis.

Even though her symptoms and tests clearly showed that the UTI was the most likely cause of the sepsis, hospital staff did not sufficiently act on this and focussed on treating the chest infection. The hospital also failed to monitor her condition and ensure that Anna was given enough fluids. This meant she wasn’t given the correct antibiotic until 15 hours after she had been admitted. By this point, it was too late and she suffered a heart attack and died.

The Ombudsman found that the Trust’s local investigation did not acknowledge that if it had provided the right treatment then Miss Hemmings could have survived, causing her parents and family considerable distress.  

Rob Behrens, Parliamentary and Health Service Ombudsman, said:

Doctors and nurses do an important job in caring for hundreds of thousands of people every day under enormous pressure. But as this case shows, it is essential that the NHS learns from mistakes and ensures that sepsis is promptly diagnosed and treated. This will ultimately save lives.

‘This case also highlights the importance of people speaking up when things go wrong so that changes and improvements are made to NHS services.’ 

Dr Ron Daniels, Chief Executive of the UK Sepsis Trust, said:

Sepsis is a complex condition in which early recognition demands an alert healthcare system. We must never become accustomed to cases such as this tragic death of a young woman in which the system failed her. Healthcare organisations must learn from such events and take robust steps to ensure that mistakes are never repeated.

‘Time and time again, we hear about the additional challenges faced by patients with physical or learning disabilities, who may present different symptoms or physiology and may communicate differently.

'When caring for disabled patients, it is critically important that our index of suspicion is heightened further, and that particular attention is paid to any patient concerns or those of others who know the patient well, and every effort is made to identify possible hidden sources of infection.’

The Ombudsman’s 2013 Time to Act report identified a number of themes in its sepsis casework, some of which were present in this case. These were failure to:

  • do the necessary tests to quickly identify the source of infection
  • monitor regularly 
  • start appropriate treatment quickly.

Following the Ombudsman’s investigation, the Trust wrote to the mother to acknowledge and formally apologise for the failings in her daughter’s treatment.

Notes to Editors:

  1. The Parliamentary and Health Service Ombudsman (PHSO) provides an independent and impartial complaint handling service for complaints that have not been resolved by the NHS in England and UK government departments. We look into complaints where someone believes there has been injustice or hardship because an organisation has not acted properly or has given a poor service and not put things right. We share findings from our casework to help Parliament scrutinise public service providers and to help drive improvements in public services and complaint handling.
  2. Part of the Ombudsman's new corporate strategy for 2018-21 is to increase transparency and the impact of our casework. This case summary forms part of an interim measure to move towards publishing the majority of our casework on our website over the next three years. Sharing insight and learning from our casework will help to improve public services. 
  3. World Sepsis Day is on 13 September each year. It aims to raise awareness of the condition and increase prevention. 
  4. Severe sepsis or septic shock occurs when infection overcomes the body’s defence mechanisms causing tissue damage and eventually multiple-organ failure. A sepsis infection is very common but severe sepsis is a rare complication. The infection can spread rapidly and can be hard to detect and diagnose. Severe sepsis causes around 44,000 deaths a year in the UK, a third of which are avoidable.
  5. Our Time to Act report helped put sepsis awareness on the national health agenda and prompted actions to improve outcomes for people with sepsis. These included:
    1. new education and training materials to increase awareness of sepsis among healthcare professionals
    2. a national campaign spearheaded by Public Health England and the UK Sepsis Trust to raise awareness of sepsis among parents and carers of young children
    3. the National Institute for Health and Care Excellence (NICE) produced a new guideline in 2016 and quality standard in 2017 to help NHS staff diagnose and treat this life threatening condition more quickly.
  6. In 2017-18, the Ombudsman investigated 50 complaints that related to sepsis and partly or fully upheld 19 complaints. 

You may also be interested in:

Avoidable death of woman after delayed diagnosis and poor management of sepsis

Acting on sepsis

 

Original article link: https://www.ombudsman.org.uk/news-and-blog/news/death-young-woman-sepsis-was-avoidable-ombudsman-finds

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