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 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. 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.
Michelle 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.”
Parliamentary and Health Service 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.”
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. 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.”
At the Ombudsman’s request, staff at the trust have been given extra training in sepsis management. 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.”