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Hospital sepsis death 'could have been avoided' with earlier treatment, concludes ombudsman

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Nurses and other healthcare staff at a South Yorkshire hospital missed opportunities to save a young woman’s life from sepsis, an investigation has found.

The Parliamentary and Health Service Ombudsman (PHSO) determined that the death of 26-year-old Anna Hemmings at Doncaster Royal Infirmary could have been avoided if staff had provided the right treatment sooner.

“It is essential that the NHS learns from mistakes and ensures that sepsis is promptly diagnosed and treated”

Rob Behrens

Sewa Singh, medical director at Doncaster and Bassetlaw Teaching Hospitals NHS Foundation Trust, which runs the hospital, said it was working to improve sepsis awareness and had updated guidance for all clinical staff.

Ms Hemmings, who had spina bifida, hydrocephalus and was partially sighted, was admitted to the hospital in October 2015 suffering from a chest infection, a urinary tract infection (UTI) and sepsis. 

Even though her symptoms and tests showed the UTI was the most likely cause of the sepsis, the PHSO found that hospital staff did not appropriately act on this.

Antibiotics given to Ms Hemmings for the chest infection were assumed to be adequate to also treat the UTI.

However, bacteria found in Ms Hemmings’ urine were resistant to the antibiotic given, according to the PHSO report, which has been released today to coincide with World Sepsis Day.

“The early detection and treatment of sepsis is an NHS-wide priority and we continue to put in place better education”

Sewa Singh

The more appropriate antibiotic was not given until 15 hours after Ms Hemmings was admitted, but by this time it was too late. She suffered a cardiac arrest a short time later and died.

The PHSO report (see attached PDF below) said nursing staff at the hospital had “missed opportunities” to monitor Ms Hemmings’ fluids and lactate level.

A urine dipstick was taken but the results were not recorded or reported to anyone, it stated.

Correct treatment could have also been issued sooner if staff had followed “good practice” and carried out an ultrasound in response to Ms Hemmings’ complaints of abdominal pain, PHSO noted.

The ombudsman determined that “if the appropriate antibiotics and fluids had been started earlier, the sepsis could have been treated”.

Ms Hemmings’ mother, Katie Hemmings from Doncaster, complained to the trust about her daughter’s care.

Unsatisfied with the results of the trust’s internal investigation, she took the issue to the PHSO.

“When caring for disabled patients, it is critically important that our index of suspicion is heightened further”

Ron Daniels

She was also unhappy that the trust did not examine her daughter’s case until after she issued a complaint.

The PHSO concluded the trust’s investigation was not broad enough and did not acknowledge that if it had provided the right care then Ms Hemmings’ death would have probably been avoided.

Rob Behrens, the parliamentary and health service ombudsman, said: “Doctors and nurses do an important job in caring for hundreds of thousands of people every day under enormous pressure. 

“But as this case shows, it is essential that the NHS learns from mistakes and ensures that sepsis is promptly diagnosed and treated,” he said. “This will ultimately save lives.”

He added: “This case also highlights the importance of people speaking up when things go wrong so that changes and improvements are made to NHS services.”

Trust medical director Mr Singh said Doncaster and Bassetlaw Teaching Hospitals accepted that there were aspects of care highlighted by the PHSO that could have been improved.

Rob Behrens

Rob Behrens

Rob Behrens

He added: “When Anna was brought to Doncaster Royal Infirmary, the presence of septicaemia was recognised and she was commenced on intravenous antibiotics.

“When Anna’s condition did not improve, the antibiotics were changed but sadly Anna passed away from the effects of septicaemia,” he said.

“The early detection and treatment of sepsis is an NHS-wide priority and we continue to put in place better education, the promotion of sepsis awareness across the trust and have improved guidance for all clinical staff,” he noted.

Following the ombudsman’s investigation, the trust wrote to Ms Hemmings’ mother to formally apologise for the failings in her daughter’s treatment.

Mr Singh said the trust was working closely with her and that she was also helping it mark World Sepsis Day.

Paying tribute to Ms Hemmings in an interview with Nursing Times, her mother said: “She had an absolutely fantastic sense of humour.

”She was so emotionally resilient it was unbelievable.

“She enjoyed life and enjoyed spending time with her family and friends.

“She was just a lovely young lady in every sense of the word.

“She knew what she wanted and that’s why she was so independent.”

She said Ms Hemmings lived independently in a bungalow with her dog and had applied to volunteer with the RSPCA shortly before her death.

Ms Hemmings had “some of the best years of her life” attending the Henshaws Specialist College in Harrogate for people living with disabilities and had also learnt how to use braille, her mother said.

She expressed gratitude for the support she had received from the UK Sepsis Trust since her daughter’s death and vowed to continue to work to raise awareness of sepsis in her memory.

anna dressing up at a party

anna dressing up at a party

Source: Family contributed

Anna Hemmings

Responding to the findings, Dr Ron Daniels, chief executive of the UK Sepsis Trust, said the case highlighted the importance of ensuring staff adapted their care when treating disabled patients.

He said: “Time and time again, we hear about the additional challenges faced by patients with physical or learning disabilities, who may present different symptoms or physiology and may communicate differently.

“When caring for disabled patients, it is critically important that our index of suspicion is heightened further, and that particular attention is paid to any patient concerns or those of others who know the patient well, and every effort is made to identify possible hidden sources of infection,” he said.

In 2013, the PHSO published a clinical sepsis report called Time to Act looking into 10 cases that it had investigated where patients did not receive the treatment they urgently needed.

The report highlighted a number of pervading themes, three of which the PHSO said were present in Ms Hemmings’ case, namely a failure to do the right tests to quickly identify the source of infection, a failure to monitor regularly and a failure to start appropriate treatment quickly.

For further information about sepsis and how to spot symptoms, visit the UK Sepsis Trust website. 

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