Settlement of claim for failure to diagnose sepsis after hysterectomy

Our medical negligence team has settled a claim arising from a hospital’s failure to recognise that our client was developing sepsis following gynaecology surgery for hysterectomy. She required intensive care and was left with permanent injury in the form of organ damage and tissue loss.

A hysterectomy is generally a safe operation, but as with any surgery it carries a risk of infection. Although surgical teams use sterile techniques and preventative antibiotics, bacteria can sometimes enter the body and cause infection. Sepsis occurs when the body’s response to infection becomes dysregulated and starts damaging its own tissues and organs. If untreated, sepsis can progress to septic shock, where blood pressure falls dangerously low and can lead to multi-organ failure and death.

In our client’s case, the infection itself was not negligently caused, but our investigations with expert evidence established that the failure to recognise the signs of sepsis development and to act quickly with appropriate treatment was below the standard of care required, so as to amount to a breach of duty. Furthermore, this caused our client additional injury, that would have been avoided with a good level of care.

How is breach of duty assessed?

In sepsis litigation, expert assessment of breach of duty focuses on whether the care provided fell below the standard that could reasonably be expected of a competent healthcare professional working in the same circumstances. Experts are not assessing the outcome with the benefit of hindsight, but instead  examine what information was available to the treating clinicians at the relevant time, and whether a reasonable clinician would have acted differently.

Our medical experts’ analyses began with a detailed reconstruction of our client’s clinical journey. This involved creating a chronology covering the days and hours before the diagnosis of sepsis was made. The experts reviewed our client’s nursing observations, NEWS scores, blood results, medical and nursing notes, drug charts, fluid balance records, radiology reports, and handover documentation. NEWS stands for National Early Warning Score and is a standardised scoring system widely used in the NHS to identify patients who are becoming acutely unwell, including those at risk of sepsis.

The purpose of that scrutiny was to identify when the signs of sepsis first became apparent and how the clinical team responded. We had gynaecology and intensive care experts looking at a series of key questions, including:

• Were there signs of infection that should have prompted consideration of sepsis?
• Were abnormal observations recognised and interpreted correctly?
• Was our client’s NEWS score acted upon in accordance with local policies and national guidance?
• Were appropriate investigations requested, such as blood cultures or imaging?
• Was our client reviewed by a sufficiently senior clinician when indicated?
• Were antibiotics administered within an appropriate timeframe?
• Were intravenous fluids and other supportive treatments provided promptly?
• Was deterioration recognised and appropriately escalated?
• Should our client have been transferred to a higher level of care earlier?

Our client’s case involved the issue of clinical escalation. Our experts concluded that given our client’s persistently abnormal observations, rising NEWS scores, and evidence of organ dysfunction, she needed to be seen by a senior decision-maker much earlier. The junior staff failed to escalate concerns when required, and this was a breach of duty.

The experts also paid close attention to trends rather than isolated abnormalities. They advised that a single raised heart rate or mildly abnormal blood test may not necessarily indicate sepsis. However, when several warning signs emerged together and/or deteriorated over time, a competent clinician is expected to recognise that the patient is becoming critically unwell. For this reason, even relatively small gaps in monitoring or documentation can become significant during litigation.

In our client’s case, the expert evidence was most persuasive where it identified a clear and evidence-based chronology showing precisely when opportunities to recognise developing sepsis and commence treatment were missed. Our experts were able to explain when a reasonably competent clinician should have suspected sepsis, what action should have followed, and why the failure to take that action amounted to a breach of duty of care.

Importantly, breach of duty is assessed separately from causation. An expert may conclude that care was negligent because sepsis should have been recognised six hours earlier, but a separate question then arises: would earlier diagnosis and treatment probably have made a difference to the outcome? In some cases, the answer is yes; in others, the patient may already have been on an inevitable trajectory despite the failings identified.

How is causation assessed?

In sepsis litigation, causation concerns whether the alleged delay in diagnosis or treatment made a material difference to the patient’s outcome. Even where an expert concludes that there was a breach of duty, a claim will only succeed if it can also be shown that the failure probably caused, or materially contributed to, the injury, deterioration, or death. This is often the most complex and heavily contested aspect of a sepsis claim.

Our experts assessed causation by reconstructing our client’s ‘counterfactual clinical course’ – in other words, what would probably have happened if our client had received appropriate care at the time when it should have been given.  This required a detailed review of our client’s medical records and a careful analysis of her condition at each stage of her illness.

Our causation experts focused closely on the timing of key events, including:

• recognition of sepsis;
• administration of antibiotics;
• delivery of intravenous fluids;
• senior medical review;
• escalation to critical care;
• source control measures, such as drainage of an abscess;
• transfer to intensive care where necessary.

In many cases, relatively short delays can be significant. A delay of only a few hours may allow infection to progress, cause worsening organ dysfunction, and reduce the likelihood of a successful recovery. In sepsis litigation, the expert should therefore examine whether the patient had already reached a point at which the outcome was inevitable, or whether there remained a realistic opportunity to alter the course of the illness.

The analysis was undertaken by reviewing our client’s physiological trajectory and our experts considered observations, NEWS scores, lactate levels, inflammatory markers, blood pressure readings, oxygen requirements, urine output, and evidence of organ dysfunction. The question was not simply whether our client became more unwell, but whether earlier intervention would probably have prevented her deterioration or reduced its severity.

The timing of organ injury is often particularly important. Expert evidence may seek to identify when kidney failure, respiratory compromise, circulatory collapse, or other complications developed. If the damage had already occurred before the negligent delay began, causation will not be established. Conversely, if the medical records show a period during which effective treatment would likely have prevented or limited organ damage, the causal link is likely to be stronger.

In fatal cases, experts do not need to conclude that earlier treatment would have guaranteed survival. Rather, they consider whether timely intervention would probably have avoided death or significantly improved the patient’s chances of survival. This often involves analysing published medical evidence, mortality data, and the patient’s individual risk factors. Similarly, in non-fatal claims, the focus may be on whether earlier treatment would have resulted in a better functional outcome, shorter hospital admission, reduced disability, or avoidance of specific complications.

Our expert opinion on causation was multidisciplinary. A gynaecology expert assessed the initial assessment and treatment following the hysterectomy, an intensivist considered critical care issues, and a microbiologist examined the progression of the underlying infection. Together, their evidence established our case on what we alleged should have happened, as well as what would likely have happened had appropriate care been provided.

We were ultimately successful with our client’s claim as we were able to build a detailed chronology showing a ‘window of opportunity’ during which treatment would, on balance, have altered and improved the outcome. This became a strong case once we identified a clear point at which sepsis should have been recognised, demonstrated that effective treatment was then delayed, and showed through expert evidence that the delay probably led to avoidable deterioration and permanent injury. It was this careful analysis of timing, progression, and prognosis, with the support of specialist expert evidence, that led to the successful outcome for our client.