Dr A complained about the care given to his mother (“Mrs A”) by Cardiff and Vale University Health Board (“the Health Board”). He said that, on 13 February 2014, Mrs A was admitted to the Medical Assessment Unit (“the MAU”) of the University Hospital of Wales. She was later transferred to a surgical ward (“the Ward”). Dr A said Mrs A was triaged wrongly, the medical team were late in examining her and no treatment was given. He said the MAU misdiagnosed and mismanaged sepsis and failed to follow the “sepsis pathway”. He also said:
• antibiotics were either administered late or not at all
• fluid balance monitoring was not done. His mother was septic and was unable to pass urine, but a catheter was not inserted;
• no paracetamol was given in the MAU and she remained feverish throughout her stay in the MAU;
• despite being on oxygen when she was in the MAU, she was not given oxygen during a transfer between the MAU and the Ward.
Dr A said the failings led to Mrs A suffering a cardiac arrest on 13 February. Mrs A remained in hospital until 8 March when, sadly, she died.
My investigation considered the relevant records along with comments from the Health Board and Dr A. I also obtained advice from two of my clinical advisers.
Sepsis is a common and potentially life-threatening condition triggered by an infection. If not treated quickly, it can eventually lead to multiple organ failure and death. Early symptoms of sepsis usually develop quickly and it can move from a mild illness to a serious one very quickly. Therefore, early intervention is key. If identified and treated quickly, sepsis is treatable. The Sepsis Six is a recognised set of interventions (including the giving of antibiotics) which, when delivered in the first hour, can increase the chance of survival.
My investigation found that Mrs A was suffering from sepsis. However, the Health Board failed to implement the Sepsis Six.
Mrs A should have been seen by a doctor within 10 minutes of triage; however she was not reviewed by the doctor for three and a half hours. There was a similar delay in the giving of paracetamol and, more seriously, a delay of over six hours in the giving of antibiotics.
My investigation also found that the Health Board failed to follow record keeping and complaint handling guidance.
In relation to Dr A’s complaint that Mrs A was not given oxygen during a transfer between the MAU and the Ward, it is clear that Mrs A needed supplementary oxygen and this was given in the MAU. However, it was not clear from the records whether this was provided during the transfer to the Ward. If Mrs A was transferred without oxygen this would be a serious failing. The records indicated that she was peripherally cyanosed shortly after the transfer. This fits with the possibility that she was transferred without oxygen. She then suffered a cardiac arrest.
Unfortunately, as a result of poor record keeping, my investigation could not determine with any certainty whether Mrs A was, or was not, given oxygen during the transfer. Nor could it definitively identify what role the transfer played in her suffering a cardiac arrest. The poor record keeping therefore caused uncertainty which is an injustice.
I concluded that the care provided to Mrs A on 13 February was inadequate. Therefore, I upheld Dr A’s complaint and recommended that the Health Board should:
a) Give Dr A an unequivocal written apology for the failures identified by this report.
b) Make a payment to Dr A of £4000 to reflect the:
i. distress caused by the failings in Mrs A’s care;
ii. uncertainty caused by those failings;
iii. failings in the Health Board’s handling of his complaint;
iv. provision of incorrect information during the complaint process.
c) So that appropriate lessons may be learned, share this report with the doctors, nurses and administrative staff involved in the case.
d) Formally remind the doctors and nurses involved in Mrs A’s care to follow the relevant record keeping guidance. (If needed, and within four months of the date of this report, the Health Board should implement refresher training for staff, involved in the case, who indicate that they are not fully conversant with the relevant guidance).
e) Provide me with evidence of its current process which ensures that doctors and nurses who meet with complainants are familiar with the case and the patient’s records.
f) Provide me with evidence of the existing monitoring and quality assurance mechanisms it has in place to prevent a recurrence of the failure of:
i. doctors to review a patient categorised as triage 2 within the timescales specified by the MTS.
ii. doctors and nurses to follow the sepsis pathway.
iii. doctors to ensure that the surgical review was performed by a doctor experienced enough to perform it.
iv. doctors and nurses to maintain appropriate records.
v. doctors, nurses and administrative staff to follow the Complaints Guidance.
(If the Health Board is not able to provide evidence to show that it has current suitable protocols for (e) and (f)(i) – (v) then, within four months, it should provide its plans to introduce such protocols).
g) Ensure that staff training in respect of recognising sepsis is up to date.
(If needed, and within six months of the date of this report, the Health Board should implement training for staff who indicate that they are not fully conversant with the relevant protocols).
A full copy of the report is available below.