Ombudsman warns of deaths linked to poor sepsis treatment

Abstract

By Sophie Blakemore THOUSANDS OF children and adults are dying each year because of a failure to diagnose and provide rapid treatment for severe sepsis, research by the health service ombudsman has revealed. The ombudsman’s first clinical report estimates that 37,000 people die from the infection annually. It focuses on the deaths of ten patients and highlights poor initial assessments and delays in administration of antibiotics. One case study is of an eight-yearold girl who was taken to hospital in the evening with severe vomiting, abdominal pain and lethargy. Admitted to a children’s ward with laboured breathing, raised blood pressure, a high temperature and rapid pulse, no blood tests were carried out, she was discharged home later that night and died at home the next morning. Sepsis occurs when the body’s immune system overreacts to infection, setting off a series of reactions that lead to widespread inflammation and blood clots. The most common causes are pneumonia, bowel perforation, urinary infection and severe skin infections. The report states that existing care standards and protocols for the care of people with severe sepsis, from organisations such as the National Institute for Health and Care Excellence and the Surviving Sepsis Campaign, are not being followed. Inadequate training and education of healthcare staff, documenting management plans and handover protocols were also identified in the report as needing improvement. RCN nurse adviser for infection prevention and control Rose Gallagher said that because a child’s condition can deteriorate quickly, it is important for nurses to work with the whole multidisciplinary team to identify the signs of sepsis at an early stage. ‘All members of the multidisciplinary team – nursing staff, doctors and ambulance workers – must be confident about the signs and symptoms of sepsis, and know how to seek further advice at times when it is difficult to know whether a child is in the early stages of sepsis or a self-limiting virus,’ Ms Gallagher said. ‘The really important thing is to listen to parents; they know their children best. If mum says her child is floppy and not eating properly, staff must always listen to this and act on it. It is about working with parents to get the best outcome for the child because children can go downhill very quickly when they are poorly.’