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Found 93 results
  1. Community Post
    Lets talks NEWS... Nurse and carer worry, I like to think that Critical Care outreach teams take this very seriously and that the 'worry' has a heavy influence in our management. Many of our patients may score 0, but warrant a trip to the ITU (AKI patients for instance). However, as part of our escalation policy it states that staff should alert the doctor and or the Outreach team when NEWS is 5 or 3 in one parameter. This causes the 'radar referral effect'. We often have a group of these patients on our list. Personally, I find them difficult to prioritise as they are often receiving frequent observations and have a plan. By concentrating on this group and make sure they have everything in place can take time, but... what about those not scoring in this threshold? Do they get pushed to the bottom of the list? Should nurses follow this protocol to safeguard themselves as well as the patient or are we not looking for sick patients in the right place? Don't get me wrong, the NEWS has been revolutionary in the way we deal with deterioration, but as a tool to prioritise this may not be the case. There are softer signs at play here....has anyone got any solutions to deal with the 'radar referals' Lots to discuss @Ron Daniels @Emma Richardson @LIz Staveacre @Danielle Haupt @Kirsty Wood
  2. Community Post
    When a patient has sepsis, every hour before the right antibiotics are administered, risk of death increases. What has your experience been of the challenges with dealing with patient deterioration in a larger trust or hospital, or in a community setting?
  3. Community Post
    Sepsis Awareness Month is around the corner and World Sepsis Day is on 13 September. What are you doing to raise awareness of the killer condition, which affects more than 250,000 people in the UK?
  4. News Article
    A hospital has admitted clinical negligence over maternity care failings that led to the potentially avoidable death of a 10-day-old baby, The Independent has learned. Kingsley Olasupo and his twin sister Princess were born on 8 April 2019 at Royal Bolton Hospital. Kingsley died 10 days later following a catalogue of mistakes, which included failing to screen him for sepsis. Kingsley and his sister were born premature at 35 weeks. Three days later he was admitted to the special care unit due to a low temperature and “poor” feeding. Despite being reviewed by two doctors he was not screened for an infection and not given antibiotics. His condition deteriorated and on 12 April he was diagnosed with bacterial meningitis and sepsis. Days later scans revealed he had severe brain damage and would not survive. Kingsley’s family said they had been “torn apart” by their son’s death and had pursued the trust to ensure a full independent investigation was carried out and lessons learnt. BFT launched an investigation into Kingsley’s care after Mr Olasupo and Ms Daley raised concerns over their son’s death. According to the trust’s investigation report, seen by The Independent, failings in care included that Kingsley was not screened for sepsis despite several “red flags”. Had this been done he would have been given antibiotics. When midwives first escalated concerns to the neonatal team no physical medical review of Kingsley took place. The investigation also found neonatal staff did not carry out daily reviews, and reviews that were done were incomplete and contained “inaccurate” and “misleading” information. Other failings included: “Ineffective” assessment of Kingsley’s wellbeing on the postnatal ward Poor communication between staff and poor handover processes No consideration was given to the fact Kingsley was not feeding well Inadequate recording of observations. Read full story Source: The Independent, 20 April 2022
  5. News Article
    A man died after an NHS trust failed to diagnose and treat sepsis quickly enough, a Parliamentary and Health Service Ombudsman investigation has found. Stephen Durkin died after suffering organ failure from sepsis. Stephen’s wife Michelle made a complaint to the Ombudsman after she was left floored by his sudden death which she believed was avoidable. Stephen was an otherwise healthy 56-year-old when he attended Wye Valley Trust A&E in July 2017 with chest pain. Hospital staff suspected he had a major blood vessel blockage and admitted him to a ward overnight. The next morning his overall condition had worsened but staff did not monitor him more closely, as national guidance advises, and he continued to deteriorate throughout the day. The next day Stephen was admitted to intensive care and treated for sepsis but tragically died later that evening. In the space of 48-hours his condition deteriorated rapidly but staff did not act quickly enough and the critical care team attended Stephen ten hours too late. His wife Michelle arrived at the hospital to visit Stephen, only to find that he was critically ill and unresponsive. She was left devastated by his death and turned to the Ombudsman to look into what had happened with his care. Ombudsman 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." Read full story Source: PHSO, 3 March 2022
  6. News Article
    A six-year-old girl thought to have died from sepsis was in fact suffering from a blood condition triggered by E coli infection, an inquest has found. Coco Rose Bradford was taken to the Royal Cornwall hospital in the summer of 2017 suffering from stomach problems and later transferred to the Bristol Royal hospital for children, where she died. The following year an independent review flagged up failings in her care in Cornwall and the Royal Cornwall hospitals trust apologised for how it had treated her. Her family were left with the belief she had died of sepsis and could have been saved if she had been given antibiotics. But on Friday, coroner Andrew Cox, sitting in Truro, found that Coco died from multiple organ failure caused by haemolytic uraemic syndrome (HUS). The inquest heard there is no proven treatment for HUS. Cox said Coco’s family had been misled over the sepsis diagnosis, which he said was deeply regrettable, adding: “As a matter of fact, I find Coco had overwhelming HUS, not overwhelming sepsis.” During the inquest, the court heard Coco’s family felt staff at the Cornish hospital were “dismissive, rude and arrogant” and did not take her condition seriously. Cox found that although staff had recognised the risk of HUS from the moment Coco was admitted, this was not clearly set out in a robust management plan. The coroner also said a lack of communication had made Coco “something of a hostage to fortune”. Read full story Source: The Guardian, 14 January 2022
  7. News Article
    Trust boards should start scrutinising performance against new indicators set out by NHS England this month as part of a national push to iron out unwarranted variation in performance on key sepsis blood tests, according to an NHSE report. Blood cultures are the primary test for detecting blood stream infections, determining what causes them, and directing the best antimicrobial treatment to deal with them. However, it is too often seen as part of a box-ticking exercise, according to a report published by NHSE yesterday. Improving performance on this important pathway should be integrated into existing trust governance structures for sepsis, antimicrobial stewardship, and infection control “to help secure a ‘board to ward’ focus on improvement,” the report says. It says there is too much variation in how blood cultures are taken prior to analysis and sets out two targets for trusts to use to standardise their collection. The first is ensuring clinicians collect two bottles of blood, each containing at least 20ml for culturing. The more blood collected, the higher the rate of detecting bloodstream infections. Blood culture bottles “are frequently underfilled”. The second is ensuring blood cultures are loaded into an analyser as fast as possible, within a maximum of four hours, because delaying analysis reduces the volume of viable microorganisms that can be detected. Read full story (paywalled) Source: HSJ, 1 July 2022
  8. News Article
    Two drugs that combat superbugs are being introduced on the NHS, offering a lifeline to thousands of patients with deadly infections such as sepsis which fail to respond to antibiotics. About 65,000 people a year in the UK develop drug-resistant infections and 12,000 die, many after routine operations or from infections such as pneumonia or urinary tract infections. These superbugs such as MRSA have mutated to develop resistance to many different types of antibiotics as a result of overuse of the drugs. It means patients end up dying from common infections that would previously have been easily treatable with antibiotics. In a attempt to “turn the tide” on antibiotic resistance, the NHS has announced a deal for two drugs, cefiderocol and ceftazidime–avibactam, which can kill bacteria that is resistant to many other types of drugs. The drugs, manufactured by Shionogi and Pfizer respectively, will save the lives of about 1,700 patients a year. They will be offered to patients with conditions such as drug-resistant pneumonia, sepsis or tuberculosis who have run out of other treatment options. Amanda Pritchard, NHS chief executive, said this would make the UK a world leader in tackling “the global challenge of antimicrobial resistance”. Read full story (paywalled) Source: The Times, 15 June 2022
  9. News Article
    Dozens of patients died or suffered ‘severe harm’ after long waits for ambulances during a three-month period in a health system facing ‘extreme pressure’ on its emergency services. The 29 serious incidents in Cornwall included patients waiting many hours for assistance despite being in “extreme pain”, patients having suspected sepsis, patients in cardiac arrest, and patients experiencing a stroke. The incidents were reported to the Care Quality Commission by staff at South Western Ambulance Service Foundation Trust during an inspection of the Cornwall integrated care system’s urgent and emergency care services. According to the CQC, the pressures on the ambulance service were “unrelenting”, while “significant work” was needed to “alleviate extreme pressure”. This meant there was a “high level of risk to people’s health when trying to access urgent and emergency care in the county”, the report said. Read full story (paywalled) Source: HSJ, 27 May 2022
  10. News Article
    Doctors are receiving "inadequate" training about the risk of sepsis after a mother-of-five died following an abortion, a coroner has warned. Sarah Dunn, 31, died of "natural causes contributed to by neglect" in hospital on 11 April 2020, an inquest found. Assistant coroner for Blackpool and Fylde, Louise Rae, said Ms Dunn had been treated as a Covid patient even though the "signs of sepsis were apparent". Her cause of death was recorded as "streptococcus sepsis following medical termination of pregnancy". In her record of inquest, the coroner noted Ms Dunn was admitted to Blackpool Victoria Hospital in Lancashire on 10 April 2020. She was suffering from a streptococcus infection caused by an early medical abortion on 23 March, which had produced sepsis and toxic shock by the time she was admitted to hospital. The coroner said "signs of sepsis were apparent" before and at the time of Ms Dunn's hospital admission but she was instead treated as a Covid-19 patient. "Sepsis was not recognised or treated by the GP surgery, emergency department or acute medical unit and upon Sarah's arrival at hospital, the sepsis pathway was not followed," she added. Read full story Source: BBC News, 19 May 2022
  11. Content Article
    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.
  12. Content Article
    In her report, the Coroner states his main concerns as follows: Informed consent and maternal choice regarding mode of delivery That this appears to be a recurring theme in obstetric practice. The culture in this area appears to still not fully accept the principles of informed consent set down in case law of the appeal courts (Montgomery) and in NICE guidance (Caesarean Section). It also does not seem to prioritise the wishes of pregnant women or holding full and frank discussions about the risks and benefits and pros and cons of different options. He noted that he had concerns that situations might arise, like it appears happened in Rhian’s case, where maternal requests are being made for re-consideration of the mode of delivery owing to feelings of physical weakness, pain or developing ill health. Evidence heard at Rhian’s inquest demonstrated that there was very little, if indeed any, recorded (in medical records) discussion held between midwives/obstetricians and Rhian regarding mode of delivery, maternal wishes and risk and benefits of differing management plans. Infection risk of retained foetus following feticide That a significant infection risk (retention of a deceased foetus) is not being given due weight in clinical decisions when a mother is attending for delivery (following feticide). There does not appear to be any specific or detailed local, or indeed national, guidance, for obstetricians and midwives which addresses this issue or discusses important considerations such as whether infection can be controlled by antibiotics alone or whether swifter methods of foetal delivery, such as a caesarean section, should be considered, or indeed whether specific microbiology advice needs to be obtained as part of a multi-disciplinary team approach. That while cases such as Rhian’s may be rare, consideration could be given as to whether more detailed and specific guidance should be made available to assist clinicians when treating mothers in maternity units following feticide. This report was sent to Worcestershire Acute Hospitals NHS Trust, Birmingham Women and Children’s Hospital NHS Trust, the Royal College of Obstetricians and Gynaecologists and the Healthcare Safety Investigation Branch.
  13. Content Article
    In her report, the Coroner states her main concerns as follows: Ms Bruce was cared for in the community by several different District Nurses. This meant that it was not the same nurse who was always seeing the wound. No photographs were taken for reference and the electronic records could not be accessed by the District Nurses while they were in Ms Bruce’s home. This meant that all information that could have been available was not, meaning Ms Bruce’s change in condition was not fully appreciated. Leicestershire Partnership Trust has learned from this and District Nurses now have work mobile phones so that they can take photographic evidence of wounds as well as IT technology that means they can access the electronic records while they are with the patient. In addition, they also have a ‘sepsis’ bag containing equipment to record a patient's blood pressure, oxygen saturation levels and temperature. Although this lesson has been learned and changes made to prevent future deaths locally, the concern is that the practice that was in place at the time of Ms Bruce’s death may be practice elsewhere. This report was sent to the Department of Health and Social Care, Leicestershire Partnership NHS Trust and University Hospital of Leicester NHS Trust.
  14. Content Article
    Findings Findings of this investigation included: The existing systems for triage do not always take into account the colour of a patient’s skin. This may influence a healthcare professional’s assessment of an infant’s/child’s physical signs. Staffing standards that relate to the treatment of children in emergency departments cannot always be met due to workforce challenges, particularly in hospitals without a dedicated paediatric emergency department. Sometimes parents describe feeling powerless when trying to articulate their concerns for their child. Some healthcare professionals do not always consider or listen to what parents are telling them. The Association of Ambulance Chief Executives are not currently involved in the ongoing national work to develop early warning scores for infants and children. Undergraduate training for paramedics on the identification of sick infants/children is variable across England. There is inconsistency across English ambulance services in training for ambulance personnel, including paramedics and non-registered clinicians, on the identification of sick infants/children. Recommendations The report makes the following safety recommendations: HSIB recommends that the Chair of the NHS System-wide Paediatric Observations Tracking (SPOT) Programme ensures that the Association of Ambulance Chief Executives, community NHS 111 providers and primary care services are integral members of the NHS SPOT Programme. HSIB recommends that NHSX develops national standards describing the electronic deployment of the NHS System-wide Paediatric Observations Tracking (SPOT) e-PEWS (the digital version of the Paediatric Early Warning Score tool), in collaboration with the NHS England and NHS Improvement SPOT Programme. This should include specifications for data capture, calculation of the score and escalation status, and also the display of the information and connectivity with other digital systems. HSIB recommends that the Chair of the NHS System-wide Paediatric Observations Tracking (SPOT) Programme ensures that any resources produced include examples of children and young people with non-white skin showing signs of serious illness. HSIB recommends that the Association of Ambulance Chief Executives works together with the ambulance services to share best practice in relation to paediatric training, education resources, frequency and types of training, and that it collates and shares areas of best practice. HSIB recommends that the College of Paramedics works with partners and higher education providers to develop, agree and implement standards for paediatric education for the future ambulance service workforce. Response from Patient Safety Learning Patient Safety Learning welcomes the publication of this new report by HSIB looking at ways to improve patient safety in relation to recognition of the acutely ill infant and child. Our reflections on this report are as follows: Increased collaboration within the NHS SPOT Programme We welcome HSIB’s recommendation that the NHS SPOT Programme should ensure it includes involvement from the Association of Ambulance Chief Executives, community NHS 111 providers and primary care services. The tragic circumstances of Mohammad’s death clearly emphasise the important role that each of these different services can play in the process of recognising life-threatening bacterial infections in very young patients. Health inequalities This investigation specifically draws attention to how existing systems for triage in primary and secondary care are not always considering the colour of a young patient’s skin, noting the impact this may have on a healthcare professionals’ assessment of physical signs. The report indicates that the importance of considering how symptoms and signs can present differently on dark skin has been highlighted in Mind the Gap: A handbook of clinical signs in Black and Brown skin. They also refer to the ongoing work of the Skin Deep Project, which aims to develop a free, open-access bank of high-quality photographs of medical conditions in a range of skin tones for use by both healthcare professionals and the public. We welcome HSIB’s specific recommendation that the SPOT programme should seek to ensure its resources include examples of children and young people with non-white skin showing signs of serious illness. We know however that safety issues faced by patients due to the colour of their skin are not limited to these specific cases. In line with the ambition set out in the NHS Long Term Plan to take a more concerted and systematic approach to “reducing health inequalities and addressing unwarranted variation in care”, we believe this should be a priority issue for the NHS National Patient Safety Team. We would like to see them working together with the Dr Bola Owolabi, Director – Health Inequalities at NHS England and NHS Improvement, to scope a potential programme of work in this area. Listening to parents The report highlights communication concerns from Mohammad’s parents, noting “the family’s perception is that they trusted what staff were telling them but that they were ultimately not listened to”. This remains a recurring problem in healthcare and emerges time and again in patient safety failings. Too often concerns raised by patients and family members are not acted on and, when harm occurs, they are left out of the investigation process. In our report, A Blueprint for Action, we set out what we believe is needed to progress towards a patient-safe future, identifying six foundations of safe care. Patient engagement is one of those six foundations. In this, we outline how patients should be engaged for safety at the point of care, if things go wrong, in improving services, advocating for changes and in holding the system to account. The value of early warning scores The report highlights that research shows that existing early warning scores are not sensitive or specific enough to help health professionals to distinguish between a seriously unwell infant/child and one with a mild viral illness. It states that “changes in vital signs (for example temperature, heart rate and respiratory rate) may be predictors of deterioration in an infant or child but they may also simply reflect that a child is unwell but not at significant risk”. We find it surprising therefore that there is not a reflection or recommendation on the need to support clinicians in their assessment of deteriorating patients, such as the further development of early warning scores. Review of ambulance service training The report notes the following safety observation: “It may be beneficial if the 10 English ambulance services review and assess their paediatric training provision and report this assessment to their trust board.” HSIB explains this observation is intended to “identify all clinical staff working in the ambulance service that have accessed ‘Spotting the sick child’ or equivalent training as an education resource and find out how often it has been accessed, and to highlight any gaps in training needs for recognition of the acutely ill infant/child”. It is our view that it would be preferable for this to be a specifically cited safety recommendation for implementation and response.
  15. News Article
    Advice on how new mothers with sepsis should be treated is to change after two women died of a herpes infection. The Royal College of Obstetricians and Gynaecologists says viral sources of infections should be considered and appropriate treatment offered. This comes after the BBC revealed one surgeon might have infected the mothers while performing Caesareans on them. The East Kent Hospitals Trust said it had not been possible to identify the source of either infection. Kimberley Sampson, 29, and Samantha Mulcahy, 32, died of an infection caused by the herpes virus 44 days apart in 2018, shortly after giving birth by Caesarean section. Their families were told there was no link between the deaths but BBC News revealed on Monday that both operations had been carried out by the same surgeon. Documents we uncovered showed that the trust had been told two weeks after the second death that "it does look like surgical contamination". Edward Morris, President of the Royal College of Obstetricians and Gynaecologists, which set standards in maternity care, said routine investigation and management of maternal sepsis "should always consider viral sources of infection, and appropriate changes should be instituted to support earlier diagnosis and treatment". Medics treating Ms Sampson and Mrs Mulcahy assumed they were suffering from a bacterial infection and didn't prescribe the anti-viral medication that may had saved their lives. The Royal College said the two deaths should be "fully investigated" as "surgical infection appears to be a significant possibility". But BBC News has learned that the East Kent Hospitals Trust, which treated both women, never told the coroner's office that the same surgeon had carried out both operations or that an investigation they had ordered had suggested the virus strains the two women had died from appeared to be "epidemiologically linked". Read full story Source: BBC News, 23 November 2021
  16. News Article
    An acute trust has been fined £2.5m after pleading guilty to charges of failing to provide safe care after the deaths of two patients. The Care Quality Commission brought charges against The Dudley Group Foundation Trust earlier this year over care failings in two separate cases which the regulator said exposed two patients to “significant risk of avoidable harm”. The trust pleaded guilty to the charges in July and was fined during a sentencing hearing today. The cases, involving 33-year-old mother of six Natalie Billingham, and 14-year-old Kaysie-Jane Bland [also known as Kaysie-Jayne Robinson], were both in 2018 and related to care at the trust’s Russells Hall Hospital in Dudley. Ms Billingham was admitted to Dudley’s Russells Hall Hospital with numbness in her right foot on 28 February 2018 and died on 2 March of organ failure caused by a “time critical” infection. The court was told she was initially thought to have a deep vein thrombosis after a three-minute triage that failed to identify "disordered" observations. The hospital then had multiple reasons to reconsider the initial diagnosis, but opportunities for review were "missed or ignored". In the case of Kaysie-Jane, who had cerebral palsy, an "early warning score" was inaccurate, meaning a sepsis screening tool was not triggered. The CQC said the care both patients received at Russells Hall Hospital was undermined by the Dudley Group’s failure to address known safety failings which the regulator repeatedly raised with the trust in the months before their deaths. The CQC said the trust did not take all reasonable steps to make improvements, despite its intervention. The trust has denied it did not react to the concerns raised. Failings included errors in the hospital’s initial assessments and monitoring of both patients, which hindered the timely escalation of concerns. A lawyer acting on behalf of the Dudley Group NHS Foundation Trust had admitted the trust failed to provide treatment in a safe way, resulting in harm, in February and March 2018. Read full story (paywalled) Source: HSJ, 19 November 2021
  17. News Article
    Some hospitals are using an out of date triaging tool for emergency patients suffering from sepsis that could leave them at risk of harm. A warning has been issued to NHS trusts to make sure their triage tools are up to date with the latest advice after several reported incidents in accident and emergency departments. The Royal College of Emergency Medicine flagged the risk to NHS England in a letter seen by The Independent warning patients could come to harm if action wasn’t taken. NHS England and NHS Digital has issued an alert to hospital chief executives warning of a potential safety risk. It told members: “The latest version of the system has updated treatment priorities especially in relation to the treatment of adult and paediatric sepsis. It is therefore crucial that if your organisation uses the Manchester Triage System clinical risk management triage tool, please ensure that the most recent version is being used and where this is not the case, specific local mitigation for the risks is in place.” It added that hospitals should ensure the latest versions of any clinical systems were being used to safeguard patient care. Read full story Source: The Independent, 8 April 2021
  18. News Article
    A young NHS patient suffering a sickle cell crisis called 999 from his hospital bed to request oxygen, an inquest into his death was told. Evan Nathan Smith, 21, died on 25 April 2019 at North Middlesex Hospital, in Edmonton, north London, after suffering from sepsis following a procedure to remove a gallbladder stent. The inquest heard Smith told his family he called the London Ambulance Service because he thought it was the only way to get the help he needed. Nursing staff told Smith he did not need oxygen when he requested it in the early hours of 23 April, despite a doctor telling the inquest he had “impressed” on the nurses he should have it. Smith’s sepsis is thought to have triggered the sickle cell crisis – a condition that causes acute pain as blood vessels to certain parts of the body become blocked. Barnet Coroner's Court heard Smith, from Walthamstow in east London, might have survived if he had been offered a blood transfusion sooner but the hospital’s haematology team were not told he had been admitted. Read full story Source: The Independent, 3 April 2021
  19. News Article
    An investigation into the outbreak of a bacterial infection that killed 15 people has found there were several “missed opportunities” in their care. Mid Essex Clinical Commissioning Group has released the outcome of a 10-month investigation into a Strep A outbreak in 2019, which killed 15 people and affected a further 24. The final report was critical of Provide, a community interest company based in Colchester, as well as the former Mid Essex Hospital Services Trust (now part of Mid and South Essex Foundation Trust). It said: “This investigation has identified that in some cases there were missed opportunities where treatment should have been more proactive, holistic and timely. These do not definitively indicate that their outcomes would have been different.” Investigators found that 13 of the 15 people that died had received poor wound care from Provide CIC. They reported that inappropriate wound dressings were used and record keeping was so poor that deterioration of wounds was not recognised. Even wounds that had not improved over 22 days were not escalated to senior team members for help or referred to the tissue viability service for specialist advice, with investigators told this was often due to concerns over team capacity. The report, commissioned by the CCG and conducted by consultancy firm Facere Melius, said: “[Some] individuals became increasingly unwell over a period of time in the community, yet their deterioration either went unnoticed or was not acted upon promptly. Sometimes their condition had become so serious that they were very ill before acute medical intervention was sought”. Other findings included delays in the community in the taking of wound swabs to determine if the wound was infected and by which bacteria. It said in one case nine days elapsed before the requested swab took place. Even after Public Health England asked for all wounds to be swabbed following the initial outbreak, this was only conducted on a single patient. In other cases there were delays in patients being given antibiotics and this “could have had an adverse impact on the treatment for infection”. It also found that sepsis guidelines were not accurately followed, wounds were not uncovered for inspection in A&E, and some patients were given penicillin-based antibiotics despite penicillin allergies being listed in their health records. Read full story (paywalled) Source: HSJ, 17 September 2020