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Avoidable deaths from sepsis; are lessons being learnt?

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    A further blog considering the investigation into the death of 3 year old Sam Morrish in December 2010 in light of the recent report of another tragic and avoidable child death from sepsis.

    By Kerstin Kubiak

In June 2014 the Parliamentary and Health Service Ombudsman (PHSO) published their report: “An avoidable death of a three-year-old child from sepsis”. This report was instigated following a complaint raised by the parents of Sam Morrish, who died in December 2010 following a short illness. The report looked at both the care Sam received, the way in which his parents’ complaint was handled and the lack of bereavement support for them. There were a number of different NHS care providers and agencies involved in Sam’s care resulting in a complex investigation and very detailed report.

The report of the Ombudsman makes for very sad reading indeed, the factors leading to Sam’s death were entirely avoidable had he received the correct standard of care and if the different NHS bodies involved took a more inter-linked holistic approach when looking at the bigger picture of a developing serious illness. In particular the Ombudsman lamented the lack of focus on symptoms of sepsis with early referral for emergency care, this is despite their report on sepsis, “Time to Act”. The loss of their child has been unbearable for this family, their pain only compounded by the poor NHS complaints investigation, necessitating a protracted investigation by the Ombudsman.

Summary of circumstances:

The basic facts of this case are that Sam presented as an ill child during a flu epidemic in the South West in December 2010. He was first seen by his GP on 21st December who prescribed antibiotics, despite this the next day his mother was concerned about his worsening condition. Sam was seen by a second GP in the afternoon of 22nd December who gave cough syrup and sent him home. He probably had early signs of pneumonia at this time, however his chest was recorded as “clear” when in all probability it was not. Later that evening his mother was again concerned and contacted NHS Direct, she spoke to a nurse who did not advise taking Sam to A&E but arranged for a GP to call, after which time Sam was taken to see a GP at an out of hours treatment centre. Once seen he was immediately referred to A&E, arriving at Torbay hospital at 10.30pm. He wasn’t given antibiotics until 1.30am and had inadequate fluid support. Despite treatment Sam tragically died as a result of pneumonia and sepsis in the early hours of 23rd December.

Summary of key findings and recommendations regarding the care:

There are a number of findings and recommendations in the PHSO’s report, this a brief summary of the critical findings relating to the care provided.

  • That the second GP who saw Sam should have properly recorded Sam’s heart rate (a high heart rate is a warning sign of sepsis); he failed to do so as he felt it wasn’t a requirement under the early warning “traffic light” system, but in fact it was required in assessing a child with a fever. The Ombudsman notes this can be confusing and recommends that NICE implement a heart rate recording requirement under the traffic light system also.
  • A critical finding related to the call with NHS Direct nurse  who failed to record that Sam had blood in his vomit, had she done so Sam should have been referred immediately to A&E. In addition she adhered too much to the “algorithm” of questions on the screen in front of her rather than making an over all clinical decision on the information provided by the mother. This does however boil down to human error, therefore NHS systems need to be more robust in protecting against this, for a child died because one question was incorrectly inputted into a computer system.
  • When Sam was taken to treatment centre his mother had to flag down assistance from a passing nurse as no priority had been attached to his referral there. Once at Torbay Hospital there were further failures in acting upon the fact Sam had sepsis secondary to his lung infection. Early warning scores were not properly recorded. Doctors should have contacted Bristol for specialist paediatric intensive care advice.
  • It was not until Sam was in the HDU unit that the antibiotics prescribed in A&E were administered. The explanation provided by the Trust was inconclusive and ranged from administrative errors, and to a lack of nurses in A&E, and even to a reluctance on the part of A&E staff to calculate paediatric dosages.
  • Further comment was made about a lack of coordination between different NHS services so that an overall clinical picture of a child worsening was not picked up. The Ombudsman note that on each occasion the mother contacted the NHS, the increased concern should have been a prompt to act, rather than having been reassured by previous contacts.

Conclusions:

The facts here speak for themselves in showing how badly Sam and his parents were let down by the NHS system. It is hard to take in how this young child was failed by every medical centre or service provider involved in his care, it was a whole cascade of errors.

Mrs Morrish was fully entitled to rely on the medical advice given and indeed was following government campaigns not to rush to A&E departments, but this mantra cannot apply in all cases and we must accept that parents alarm calls are extremely serious and should be listened to. Sepsis is the second largest cause of death in the UK, it’s appalling that basic vital signs in an ill child were not recorded and ongoing deterioration with significant symptoms were not acted upon.

The failure to quickly and properly investigate this death has led to gaps in the investigative process in terms of fact finding; injustice for Sam and his parents was used to describe this. Indeed it in turn leads to an inability to make full conclusions and recommendations. Have lessons been learnt? Unfortunately the answer to that is only maybe, for there is no point learning of errors if you don’t make every effort to prevent them occurring again and it seems from this week’s reports of a further child death from sepsis that there is still a long way to go.

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