24 May 2015
Failure to Recognise and Manage Sepsis in the NHS is a Recurring Issue
A new report by the Health Ombudsman has highlighted a number of serious NHS failings in London hospitals that include errors made during surgery, delays in the diagnoses of tumours and failings to recognise and manage sepsis.
The report, based on investigations by the Parliamentary and Health Service Ombudsman, examined two dozen complaints brought against London NHS Trusts between July and September 2014.
One case involved a woman whose spinal tumour was missed by neurologists at Basildon and Thurrock University Hospitals NHS Foundation Trust, only to be discovered five months later by which time she had trouble walking.
Another case involved a man who was left with permanent pain and numbness when surgeons at Barts Health NHS Trust damaged nerves during surgery, while a third case concerned a woman who died from sepsis after suffering abdominal pain and blood in her urine. The Ombudsman found that staff at Imperial College Healthcare NHS Trust failed to assess and treat her with appropriate antibiotics quickly enough.
Sepsis is a common and potentially life-threatening condition that occurs when the immune system responds to an infection. The body’s reaction to an infection can cause inflammation, raised blood pressure and blood clotting problems. If not treated promptly, sepsis can lead to multiple organ failure, strokes, severe disability and death.
Previous research by the Health Ombudsman revealed that delays in diagnosing and treating sepsis are causing unnecessary deaths in our hospitals. Every year, an estimated 100,000 people in the UK are admitted to hospital with sepsis and around 37,000 people die as a result of the condition.
The failure to recognise and manage sepsis is a recurring issue in many of our most serious cases and often crops up when people are admitted to hospital over the weekend.
Staff are trained to use Early Warning Score systems (known as MEWS) to recognise when observations of temperature, pulse and blood oxygen levels suggest a developing problem. In our own experience however, either these observations are never made or the warning systems are not followed.
Examples of cases we have dealt with involving patients who have suffered sepsis include:
- A 36-year-old man who was admitted to hospital with a serious knee injury involving artery damage in his leg. He developed sepsis over a weekend but there were delays in recognising the condition. By the time staff noticed the sepsis, it was too late to save his leg and he had to undergo an above-knee amputation.
- A 43-year-old man with an untreated hip infection was admitted to a London hospital on a Friday evening. He began to develop sepsis on the Saturday afternoon. But by the time staff realised late on the Sunday his heart was affected and he needed emergency surgery. His treatment was too late to avoid a stroke which left him brain damaged, unable to walk and in need of 24-hour care.
- A 30-year-old man was seen in the Minor Injuries Unit of a London hospital where a doctor failed to recognise his serious condition. The man collapsed and died the following morning.
- A woman in her 70s who developed sepsis over the weekend after an operation to remove her gallbladder. By the time staff realised how seriously ill she was, it was too late to save her life and she died on the Monday morning.
Not only are failures in recognising and managing sepsis a serious shortcoming in our health service but the problems they cause are among the most severe possible. MEWS systems are in place in hospitals for a reason and it is difficult to understand why the management of sepsis so often falls below acceptable standards.
The NHS needs to do much more to save lives by improving the care of patients with sepsis. It is clear from this report that serious lessons need to be learned to prevent errors like these from occurring in the future – errors which can obviously have a devastating impact on patients and their families.
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