Death of 26-year-old Doncaster woman from sepsis was avoidable, Ombudsman rules
THE death of a 'lovely' and 'fiercely independent' young woman from Doncaster from sepsis could have been avoided, an investigation has found.
Staff at Doncaster Royal Infirmary “did not sufficiently act” to treat sepsis when Anna Hemmings was admitted in October 2015 suffering from the serous infection, a urinary tract infection (UTI) and a chest infection - despite her symptoms and tests clearly showing that the UTI was the most likely cause of the sepsis.
Miss Hemmings, 26, who had spina bifida, hydrocephalus and was partially sighted, was not monitored sufficiently or given enough fluids, and was only given the correct antibiotic 15 hours after she had been admitted. By this point, it was too late and she suffered a heart attack and died, the Parliamentary and Health Service Ombudsman (PHSO) said.
The Ombudsman found that Doncaster and Bassetlaw Teaching Hospital Trust’s local investigation did not acknowledge that if it had provided the right treatment, then Miss Hemmings could have survived, causing her parents and family considerable distress.
The Trust has since apologised to Miss Hemmings mother, Katie Hemmings, who is now working with the charity the UK Sepsis Trust to highlight the dangers of the condition.
Mrs Hemmings told the Yorkshire Post: “Anna was a lovely young lady, and despite her special needs was fiercely independent, returning to Doncaster to live on her own after studying at Henshaws Specialist College in Harrogate.
“She had survived sepsis before when she was 13, so we know it can be treated, now we want to make sure everyone, young and old, is aware of the symptoms.”
Medical director Sewa Singh said: “We accept that there were aspects of care which the Parliamentary and Health Service Ombudsman (PHSO) identified could have been improved.
“When Anna was brought to Doncaster Royal Infirmary, the presence of septicaemia was recognised and she was commenced on intravenous antibiotics. When Anna’s condition did not improve, the antibiotics were changed but sadly Anna passed away from the effects of septicaemia.
“The early detection and treatment of sepsis is an NHS-wide priority and we continue to put in place better education, the promotion of sepsis awareness across the Trust and have improved guidance for all clinical staff.
“We are pleased to have been able to work closely with Anna’s mother, Katie, who will join us as we mark World Sepsis Day today.”
Parliamentary and Health Service Ombudsman, Rob Behrens, said: “Doctors and nurses do an important job in caring for hundreds of thousands of people every day under enormous pressure. But as this case shows, it is essential that the NHS learns from mistakes and ensures that sepsis is promptly diagnosed and treated. This will ultimately save lives.
“This case also highlights the importance of people speaking up when things go wrong so that changes and improvements are made to NHS services.”
Chief executive of the UK Sepsis Trust, Dr Ron Daniels, said: “Sepsis is a complex condition in which early recognition demands an alert healthcare system. We must never become accustomed to cases such as this tragic death of a young woman in which the system failed her. Healthcare organisations must learn from such events and take robust steps to ensure that mistakes are never repeated.
“Time and time again, we hear about the additional challenges faced by patients with physical or learning disabilities, who may present different symptoms or physiology and may communicate differently. When caring for disabled patients, it is critically important that our index of suspicion is heightened further, and that particular attention is paid to any patient concerns or those of others who know the patient well, and every effort is made to identify possible hidden sources of infection.”