Lessons from sepsis misdiagnosis

The Parliamentary and Health Service Ombudsman has published a report looking into the avoidable death of a three-year-old child from sepsis.

The report relates to the care received from medical practitioners at various facilities including, amongst other healthcare providers, South Devon Healthcare NHS Foundation Trust, as well as the way in which the complaint from the parents was dealt with.

The incident

A three-year-old boy, Sam, was taken to his GP’s with a high fever which had been present for five days. Despite this being an amber warning on the traffic light system for children, the GP prescribed antibiotics and sent him home, albeit with an adequate safety net in place. This means that the parents had been told what to do if Sam’s condition worsened. Full notes of the appointment were not recorded.

When Sam’s symptoms worsened the next day, the GP practice was called and the parents were put on a callback list. After speaking to both a nurse practitioner and a GP, an appointment was made for late afternoon. Again, a different GP failed to treat Sam with the urgency the traffic light system suggested, and again, full notes of the appointment were not recorded. When the parents left the surgery, they had not been told what to do in the event that Sam’s condition worsened.

An out of hours call to NHS Direct was deemed to be a service failure in the report due to answers to vital questions being recorded incorrectly, and as such, a non-urgent referral was give. Had the correct answers been recorded, Sam’s parents would have been directed to take their son to A&E.

The non-urgent referral was sent to Devon Doctors, and when their initial call was not answered by the parents, they did not attempt to call back. As the number was withheld, the parents did not know who they had missed a call from. Sam’s parents subsequently called Devon Doctors as they had to their knowledge, not received a call from them. Their call was not logged to the system, and non-clinical staff did not escalate the case despite the information given to them by the parents, warranting this step.

At this point the parents were told to take Sam to a local Treatment Centre. However, the urgency of the case had not been passed on to the centre and the parents had to attract the attention of a medical professional. At this point it was identified that Sam had a life-threatening condition and an ambulance was called.

Upon arrival at A&E it was clear that Sam had signs of sepsis, and was prescribed the appropriate antibiotic treatment. However, it was not administered until 2 and a half hours late. In addition, the monitoring he received was not frequent enough, and at times did not encompass all required observations. The report also found that doctors should have sought advice on treating Sam’s condition from the paediatric intensive care unit in Bristol.

Sam was finally transferred to a high dependency unit. The report has concluded that again, as his condition deteriorated, advice should have been sought from the paediatric intensive care unit in Bristol.

The report went on to uphold the parents’ complaint over bereavement support and found both the Surgery and the Trust fell far short of the expected standards.

Sam’s parents also had cause to complain about the investigations into their son’s death and the report has found that the process has left the parents without the answers they want, and have been left with no confident in the organisations involved.

The full report from the Ombudsman can be viewed by following this link.

Fortunately, there is now an increased awareness of sepsis, and hospitals have strict guidelines surrounding diagnosis of suspected cases of sepsis.

However, as the above highlights, there can be errors made and misdiagnosis of sepsis can occur. Should you find yourself in a similar situation as highlighted in the report, you could look at the possibility of making a claim for sepsis compensation by contacting a specialist medical negligence solicitor.

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