A 56-year-old man with chest pains died after NHS staff failed to diagnose and treat sepsis quickly enough, the Parliamentary and Health Service Ombudsman has said

Bacteria

More must be done to ensure that NHS staff are aware of the signs and symptoms of sepsis, an ombudsman has said, following the avoidable death of a patient.

Stephen Durkin, a factory worker from Hereford, died after NHS staff failed to diagnose and treat sepsis quickly enough, the Parliamentary and Health Service Ombudsman (PHSO) said. The 56 year old died after staff at Wye Valley NHS Trust failed to spot that he had the life-threatening condition.

Sepsis, sometimes called septicaemia or blood poisoning, occurs when the body overreacts to an infection and starts to damage tissues and organs. If it is not treated quickly, it can result in organ failure and death. The PHSO concluded that Mr Durkin’s death could ‘so easily have been avoided’.

Staff did not act quickly enough

Mr Durkin was an otherwise healthy man when he attended the Accident and Emergency Department at Wye Valley NHS Trust in July 2017 with chest pain. Staff suspected that he was experiencing blockage of a blood vessel, and admitted him to a ward. His condition worsened overnight, but staff did not monitor him closely, as guidance dictates. The next day, he was admitted to intensive care and treated for sepsis, but died later that evening.

The ombudsman said that staff did not act quickly enough, and that the critical care team attended Mr Durkin 10 hours too late. The case was referred to the ombudsman by Mrs Durkin, who arrived at the hospital to visit her husband to find that he was critically ill and unresponsive.

Mrs Durkin said: ‘My feelings regarding his death cannot be expressed fully in words. Stephen’s death was untimely and avoidable, he had so much to live for.

‘I’m hoping that highlighting the mismanagement of Stephen’s treatment and care by Hereford hospital, which resulted in his death, can prevent anyone else from experiencing the same tragic journey myself and family have had to take.’

NHS trusts must ensure that their staff are sepsis-aware 

PHSO Rob Behrens said: ‘Stephen’s tragic death could so easily have been avoided. His case shows why early detection of sepsis, as set out in national guidelines, is crucial.

‘Sadly, this is not the first time we have had to highlight this issue. There is clearly more the NHS needs to do. It is vital that NHS trusts ensure their staff are sepsis-aware to reduce the number of avoidable deaths from this life-threatening condition.’

Dr Ron Daniels, founder of the UK Sepsis Trust, said: ‘Although sepsis most commonly affects the elderly, the very young, and those with underlying health conditions, this tragic case reminds us that it can also strike anyone, at any time.

‘The key to improving outcomes from sepsis lies in our public being aware of sepsis together with vigilant health professionals’, he said. ‘In this case, in 2017, Stephen was let down.

‘As we emerge from the COVID-19 pandemic, this serves to remind us that initiatives to raise awareness of other health conditions, particularly sepsis, have never been more needed.’

Extra training given to staff

At the ombudsman’s request, staff at the trust have been given extra training in sepsis management.

Dr David Mowbray, Chief Medical Officer at Wye Valley NHS Trust, said: ‘We apologise unreservedly to Stephen’s wife and family for the delay in his diagnosis and treatment for sepsis.

‘The trust swiftly improved training and monitoring to prevent deaths from sepsis wherever possible, and we continue to monitor and evaluate any sepsis-related deaths to ensure patients receive the highest standard of care.’

This article originally appeared on Medscape, part of the Medscape Professional Network.

Credit:

Lead image: Kateryna_Kon/stock.adobe.com

Image 1: Kateryna_Kon/stock.adobe.com