Avoidable death from failure to diagnose and treat sepsis

Case Studies

Avoidable death from failure to diagnose and treat sepsis

Sepsis is a medical emergency which must be diagnosed and treated quickly to avoid what can be devastating consequences. We have settled a case where a failure to take heed of characteristic signs of sepsis very sadly led to fatality.

Our client’s wife sustained a fall and fractured the right neck of her femur. She was taken to hospital by ambulance and admitted. A right hip hemiarthroplasty was carried out and she remained in hospital for over three weeks until she was discharged. 

At the time of discharge, she was suffering from diarrhoea with episodes of vomiting, and she complained of feeling unwell. Upon discharge home, she developed severe pain and swelling around the surgical wound. Five days later she returned to hospital by ambulance. She was in a great deal of pain and discomfort and had difficulty mobilising. There was persistent swelling at the site of the surgical wound. She had diarrhoea and vomiting, was unable to eat and drink, and looked pale. 

Her right hip dressing was changed and some slight oozing was noted. She was referred to the orthopaedics team in view of the discharge from the wound. However, she was not seen by an orthopaedic consultant until three days later. The impression was of an infected right hemiarthroplasty. Though she was consented for a washout of the right hip, surgery was delayed for a further three days, in part due to difficulties in managing her dialysis needed for kidney failure. When surgery was finally carried out, pus and necrotic tissue were found to be communicating down to the hip joint and prosthesis. 

Our client’s wife’s condition was critical following surgery, and after discussions with the family, a DNAR (‘do not attempt resuscitation’) form was completed. Care was withdrawn and she sadly died soon afterwards.

We represented the family at inquest. In his narrative conclusion, the coroner found that there was a delay in the orthopaedic doctors reviewing our client’s wife, and that the outcome is likely to have changed had there been removal of the source of infection and antibiotic cover at an earlier stage. Just prior to the inquest hearing, the hospital trust made an admission of liability, and we managed to negotiate a settlement soon afterwards.

Rosie Nelson, senior associate in the clinical negligence team, says: “This is a tragic example of what can happen if signs of sepsis are missed. Training is critical, and though huge improvements continue to be made across the NHS, we still see cases such as this where avoidable mistakes are made. We can only hope that raising awareness and the implementation of further training on sepsis will serve to reduce the number of these cases we see.”

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