Sepsis has been labelled the ‘silent killer’ that accounts for more than 44,000 deaths each year in the UK.
BBC Panorama “Why Mum Died: Britain’s Sepsis Crisis” (aired on Monday 11 September 2017) provided a personal account of Alistair Jackson, investigative reporter, and how he had used his professional investigative skills to uncover how the tell-tale signs of suspected sepsis were missed by doctors treating his mother at Queen’s Hospital in 2013. Panorama reported a number of incidents where families had been affected by sepsis either as survivors or surviving family members. Panorama highlighted a number of disturbing circumstances – most startling was the fact that many deaths, including the mother of Alistair Jackson’s, could have been prevented along with tens of thousands of others.
Alistair’s mother had woken that fatal morning and said: “I have never felt as ill as this before”. Looking at her GP notes, Alistair discovered that his mother had visited her GP in the past weeks with a urinary tract infection, often a source of the infection that leads to sepsis in the elderly.
The documentary also tells the story of Tom Ray, a surviving victim of sepsis, who has struggled to get any answers since he had all four limbs and half of his face removed after falling victim to sepsis 17 years’ ago. Panorama shows him working at a call centre, which is a change of career due to the consequences of sepsis and he says that he must have cost the NHS over £1M due to the failure of not delivering the urgent care that he needed in his first hour of admission to hospital. His wife comments that it is easy to make a mistake but it is important to learn what went wrong so no mistake is made next time.
When one-year-old William Mead lost his life in December 2014, it was put down to ‘natural causes’, yet an inquest revealed sepsis was to blame, triggered by an undetected chest infection. His mother, Melissa, fought to find out what happened. She felt that she had to be a constructive nuisance to get answers revealed. There had been a catalogue of failures. Jeremy Hunt’s apology on 25 March 2017 is shown where he states that they did not spot his sepsis.
Angela Meehan’s husband Dean died following routine surgery to fix his fractured hip. In the days that followed, he said he had never felt so ill. She explained that Dean went back to hospital four times before finally seeing his original surgeon who decided he needed a hip replacement. It was only from blood tests taken to prepare for the operation that doctors noted the high level of infection. He was called back to hospital but died four days’ later. Angela said that people should not die from a fractured hip in 2016.
He visited Dr Ron Daniels, Chief Executive of The UK Sepsis Trust, having asked him to review the medical notes of his mother’s last admission. Dr Daniels told him that this (the symptoms of a UTI, also chest infection, abnormal observations) was a loss of situation awareness. When asked if the notes contained any evidence that sepsis was considered or if there was an unacceptable delay of three hours’ from the prescription of antibiotics to administration, the responses pointed to poor care. Alistair asked if it would have made a difference if there had not been a delay in administering the antibiotics. Dr Daniels said, “I think it’s unlikely that earlier antibiotics would have done any harm and it’s entirely possible that they might have improved her chances of survival.”
Panorama shows Alistair talking to Health Secretary, Jeremy Hunt, advising him that it took two years’ of his own personal investigations to find out the truth behind his late mother’s diagnosis of sepsis. He emphasised how now having spoken to survivors and families that he felt that the same thing was happening to others. Jeremy Hunt told him that this was totally unacceptable, however the NHS were on a journey to change its culture around safety and has made significant progress: “There are preventable deaths happening but we’re bringing them down and I think that the picture is much improved from two years’ ago but there’s a long way to go.”
Alistair returned to the Burton Hospital and spoke with the new medical director of Burton Hospitals NHS Foundation Trust, Dr Magnus Harrison, regarding the progress made with diagnosing and treating sepsis since his mother’s death. Dr Harrison informed him that only around half emergency admissions showing possible signs of sepsis were getting antibiotics within that first crucial hour. NHS England has reported that just over 60 percent of A&E sepsis cases are getting antibiotics within the hour. A study has revealed that 24 out of 104 acute hospital trusts failed to administer intravenous antibiotics within the first hour to half the patients requiring treatment for possible sepsis. It is apparent that there is quite a variation around the country, pointing to a “postcode lottery” in treatment.
Panorama is given access to the pioneering approach of Nottingham University Hospitals Trust who are trialling new schemes to ensure signs of sepsis are diagnosed as quickly as possible. The Trust has adopted a sophisticated digital warning system checking all patient observations advising doctors of patients at risk of sepsis. Dr Mark Simmonds, Acute and Critical Care Medical Consultant, explained that it was about sending messages and information about patients who might have sepsis to the right people at the right time. Alistair warns getting senior clinicians to the bedside is crucial, and something that didn’t happen soon enough for his mother. Furthermore at little expense, Nottingham University Hospitals NHS Trust has a policy of an ongoing review of treating patients with sepsis to see whether they did the best for the patient. Doctors are taken through in detail by a trained sepsis nurse using a traffic light system to report how well they did and even where they did do well, they are still told what they could do better next time.
The documentary shows that the NHS still has some way to go before it gets this right. There seems to be a postcode lottery across England as a whole which was less than positive although improving. When questioned why it is taking so long after the events of three years’ ago to improve the detection and treatment of sepsis at Burton Hospital, Dr Magnus Harrison said there are time critical competing interests and that the Trust now has ten emergency nurses trained to recognise sepsis who can administer antibiotics without the need for prescription.
Alistair concluded saying his mother up to the point of death had received excellent care in the NHS but there is now a necessity to focus on sepsis awareness and prevent others from suffering as undoubtedly his family did.
The documentary can be seen for the next 12 months on https://www.bbc.co.uk/programmes/b0957545
For more information on the work of UK Sepsis Trust see https://sepsistrust.org
If you or a loved one has suffered as a result of sepsis misdiagnosis or medical negligence you may be able to bring a claim for compensation. For a free, no-obligation chat you can call our specialist Medical Negligence lawyers on Freephone 0808 164 0808 or you can complete the request a call back form and we will call you to start a free claim assessment.