Health chiefs ordered to say sorry for sepsis death
A HEALTH board has been told to apologise to the family of a woman who died of sepsis, sparking renewed calls for an NHS campaign on the deadly condition.
The 53-year-old had undergone an operation and should have been given antibiotics to combat the risk of infection.
But she fell ill with sepsis and died, promoting a complaint from her family to the NHS.
The case was published by Scotland’s Public Services Ombudsman (SPSO) yesterday and comes only days after the launch of the Scottish Daily Mail’s campaign to raise vital awareness of the ‘silent killer’ condition.
Sepsis is the severe complication of an infection and occurs when the immune system goes into overdrive, causing widespread damage.
Last week, we revealed it affects 20,000 Scots a year and kills 4,000, a toll experts are desperate to tackle. But the Scottish Government has rejected calls for a nationwide push on the issue.
Yesterday a new SPSO report investigated the death of the patient at NHS Grampian.
The woman, named as Mrs A, had cancer and underwent an emergency procedure – a nephrostomy – on each kidney in April 2016, in which a catheter is inserted to drain urine.
According to protocols at Aberdeen Royal Infirmary, she should have been given antibiotics as a precaution against the risk of an infection. However, this did not happen and the woman began to show signs of an infection. Although she was given antibiotics at that stage, she developed sepsis and died.
Ombudsman Rosemary Agnew found that while Mrs A had a ‘poor prognosis’ because her cancer had spread, prescribing antibiotics as a precaution ‘may have prevented her from developing sepsis’ although ‘it was impossible to definitively determine the effect they would have had’.
However, if Mrs A had received the antibiotics, it might have avoided sepsis and given her and her family ‘more time together’ to come to terms with her cancer diagnosis.
NHS Grampian was further criticised as it had failed to apologise to the woman’s family at the outset of the investigation, when it realised that antibiotic prescribing protocols existed for patients like Mrs A, but had not been followed. The ombudsman said NHS Grampian should apologise to the woman’s daughter, who lodged the complaint, for the ‘failure to follow local guidance’ on prescribing antibiotics.
Mrs Agnew said: ‘Mrs A was at a moderate risk of developing sepsis following the nephrostomy procedures and prescription of prophylactic antibiotics, in line with the local policy, may have prevented it occurring.
‘Although Mrs A’s prognosis was poor, this could potentially have allowed her and her family more time together to come to terms with her diagnosis and prepare.
‘The best chance of this outcome would have been offered by following the local policy.’
Last night experts said ‘urgent action’ is needed to raise awareness among NHS staff and the public of the dangers of sepsis.
Dr Ron Daniels, chief executive of the UK Sepsis Trust, said: ‘‘Until we raise public awareness, and build resilience into our health care systems, people will continue to die every day.’
An NHS Grampian spokesman said: ‘We have accepted the ombudsman’s recommendations and will implement them in full. This report will be shared in full with the relevant clinical staff.
‘We will apologise unreservedly to the family for the areas where our care has fallen short of the high standards we would expect.’