Father of 2 Died from Sepsis After Waiting 34 Hours for Medication

A new investigation has revealed the death of a father of two from sepsis, after a 34-hour delay in administering the correct medication.

The man, who had disabilities, was initially referred to Bassetlaw Hospital in Worksop, England, by his primary care physician due to a urinary tract infection.

The Parliamentary and Health Service Ombudsman (PHSO) stated in a release that the man's death could have been avoided. The 45-year-old lived in supported housing in Ollerton, Nottinghamshire, and suffered from Alexander’s Disease, a rare and incurable condition affecting the nervous system. The PHSO's statement, released Wednesday, December 10, indicated that earlier administration of antibiotics in November 2022 at Bassetlaw Hospital could have saved his life.

Despite a prescription for intravenous (IV) antibiotics, the man waited 34 hours to receive the medication while hospitalized.

The PHSO noted the man had respiratory and mobility issues, requiring round-the-clock care, including assistance with feeding and personal hygiene. Due to his condition, he had a permanent catheter, making him prone to UTIs.

His disabilities made it difficult for him to communicate his needs to medical staff. His mother voiced her concerns to hospital staff, but she was unaware that he had not yet received the prescribed antibiotics.

Paramedics and care home staff also informed the hospital that the resident of Nottinghamshire required IV antibiotics. Although his primary care physician had entered test results into an online system, the hospital did not utilize it because the request was not submitted in writing.

The hospital staff opted for an oral antibiotic after consulting with a microbiologist, but the requested drug was unavailable. The Ombudsman found that doctors should have sought further advice at that point, as IV antibiotics likely would have been recommended and available.

The man finally received the IV antibiotic 34 hours after arriving at the hospital, but at half the necessary dosage. There was also a three-hour delay between the doctors' request for the medication and its administration. By the time the second dose was administered, he had become septic and died a week later.

Rebecca Hilsenrath KC (Hon), Chief Executive Officer of the PHSO, stated that the man, unable to advocate for himself and reliant on clinicians, did not receive the necessary care, resulting in his unnecessary death. She added that losing a life through sepsis should not be an inevitability and noted the doubling of sepsis-related complaints over the past five years. The PHSO also sees poor communication between patients and clinicians and is focusing its efforts to help improve this throughout the NHS.

Hilsenrath emphasized the need for accountability, justice, and service improvements. She called for an NHS culture that is open, listens to patients and families, acknowledges mistakes, and learns from them.

The man’s mother stated that she knew her son best and tried to inform the doctors that the oral antibiotic would not be effective and that the GP had a microbiologist’s report indicating his unresponsiveness to that drug. She felt dismissed, with the doctors prioritizing their expertise over her insights as his mother. She described it as heartbreaking to learn the truth, as she was under the impression he had received some antibiotics, even if incorrect, but discovered he received no treatment during his time in the hospital.

The Doncaster and Bassetlaw Teaching Hospitals NHS Foundation Trust issued a statement expressing sincere apologies for the incident and the family's loss. They stated that they reviewed the care provided at the time through their Patient Safety Panel and implemented immediate actions to strengthen antibiotic prescription, escalation, and administration procedures.