PHSO: Failure to act on sepsis led to man’s death, Ombudsman finds (3 March 2022)

Summary

This article details the case and findings of an investigation by the Parliamentary and Health Service Ombudsman (PHSO) into the death of Stephen Durkin. Stephen died after suffering organ failure from sepsis, while under the care of Wye Valley NHS Trust. His wife, Michelle Durkin, subsequently made a complaint that delays in the diagnosis and treatment of sepsis led to her husband’s death.

Content

Stephen Durkin, a factory worker from Hereford, died after suffering organ failure from sepsis. The life-threatening condition occurs when the immune system overreacts to an infection, causing widespread inflammation that can damage the body’s own tissue.

Michelle Durkin complained about delays in the diagnosis and treatment of sepsis which led to her husband Stephen’s death. She said that the Trust did not carry out proper observations, put him under the critical care team or transfer him to intensive care quickly enough. She also complained that the Trust did not communicate effectively with her about her husband’s condition which meant she was unable to say goodbye to him.

Findings

The PHSO detailed its findings as follows:

• Our investigation found that the Trust should have detected sepsis earlier than it did. The Trust did not follow its own deteriorating patient policy to observe the patient every four to six hours within the first 48 hours. National guidance on NEWS states that if the NEWS increases, the frequency of observations should also increase. By the time the Trust saw Stephen, his NEWS had increased significantly. It is highly likely that more frequent observations would have detected this deterioration earlier, which would have prompted the Trust to consider how to treat Stephen’s worsening condition.
• We found that even when the Trust did detect the deterioration, it did not react appropriately. According to national guidance, it is essential for patients with a NEWS of seven or more to be assessed by a critical care team. The Trust did not do this until ten hours later, when Stephen’s NEWS was nine.
• We also found that the Trust did not effectively communicate with Michelle about her husband’s condition. When she called the ward, she was not told how unwell he was. If she had been, she could have got to the hospital sooner. We found this would have given her an opportunity to better prepare herself for what was to come, but this option was taken away from her.

Recommendations

Following PHSO recommendations, the Trust has agreed to: 

• write to Michelle to acknowledge the failings identified in our report and apologise for the impact they had on her.
• explain what action it will take to ensure all relevant staff involved in Stephen’s care receive training in sepsis awareness.
• pay Michelle £17,000 in recognition of the injustice she suffered as a result of its failings.