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Tragic avoidable death from undiagnosed sepsis

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    The Parliamentary and Health Service Ombudsman has produced a report relating to the death of a toddler from sepsis, in the hope that the wider NHS learns lessons from his death.

    By Simon Elliman

I was saddened to read recently about Sam Morrish, a three-year-old boy, who died unnecessarily from sepsis in December 2010. There was said to have been a “catalogue of errors” made by his GP surgery, out-of-hours doctors, NHS Direct and by the local healthcare trust. Sam was not properly assessed; in particular signs of blood in his vomit were missed, and inexplicably there was a three hour delay in administering antibiotics in hospital even after they had been prescribed.

WHAT HAPPENED TO SAM?

Sam became unwell during a flu epidemic. He had been suffering flu-like symptoms for a week by the time he was seen by a GP. He was seen twice by GPs, and then was seen at an out-of-hours GP practice before being redirected to A&E. He was admitted to hospital and prescribed antibiotics, which were not promptly administered, and he sadly died in the early hours of the following morning from sepsis.

WHAT WENT WRONG?

Both the GPs were criticised for failing to follow a guideline about “Feverish Illness in Children”. They did not properly assess the following factors:

–    Hydration
–    Breathing rate
–    Heart rate
–    Temperature

They failed to tell the family of warning signs to look out for, such as becoming lethargic and pale, and filed to signpost how to access further healthcare

At the out-of-hours centre, there was a failure to definitively assess Sam’s condition within 60 minutes. At A&E, they made the correct diagnosis of sepsis, appropriately prescribed intravenous antibiotics, but then inexplicably failed to administer them for three hours.

LESSONS TO BE LEARNED

The Ombudsman’s report set out several key areas of learning for the Trust, the GPs and the other agencies involved. These are too detailed to go into in a blog of this length, but I was particularly interested to read that a key failing on the part of the second GP was not to check whether Sam’s nappy was wet or dry, an obvious check for dehydration.

My colleague, Ali Cloak, in her blog about delayed diagnosis of sepsis in September 2013, highlighted a simple set of life-saving measures collectively known as the Sepsis 6, which have been implemented by the best hospitals to maximise the chances of saving lives and to reduce cases of undiagnosed sepsis which can lead to avoidable deaths, such as with Sam.

OUR EXPERIENCE

Lawyers at Clinical Negligence Team have represented the families of patients who have died in similar circumstances to Sam, and we are conscious that it can be very difficult to make a diagnosis of a life threatening condition in a young child.  Equally, there is an even greater burden of responsibility to avoid taking any chances with the life of a young child and it is vital to follow guidelines and recommended measures, such as the Sepsis 6.

In the wider context of sepsis, last year’s report by the Ombudsman stated that 37,000 of the 100,000 patients diagnosed with sepsis die every year, a frighteningly high figure. Clearly, much still remains to be done in raising awareness of the condition, so that the index of suspicion for making the diagnosis is set at a lower level, and so that guidelines and procedures are followed promptly once the diagnosis is made.

If you have any concerns about medical care received in connection with treatment of sepsis, or undiagnosed sepsis, and would like to discuss this with a specialist lawyer please get in touch with me or one of my colleagues.

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