Doncaster and Bassetlaw Teaching Hospitals NHS Foundation Trust

4.Mrs C complains about treatment her late son, D, received from Doncaster and Bassetlaw Teaching Hospitals NHS Foundation Trust.

5.D lived in supported accommodation due to his complex care needs. In November 2022, his GP found he had a suspected urinary tract infection. Because this required intravenous rather than oral antibiotics, the GP referred him to Bassetlaw Hospital. D went there by ambulance on 21 November 2022. After waiting in the ambulance for more than four hours, D went to the Emergency Department and was later admitted to a ward. Mrs C complains he was not given antibiotics in a timely manner, despite this being the reason for his going to hospital. He was not started on intravenous antibiotics until the early hours of 23 November.

6.D deteriorated rapidly later that day and it was decided to put him on an end-of-life care. He was discharged back to the care home and sadly died on 30 November. Mrs C believes failures in her son’s care and treatment affected his chances of surviving.

7.Mrs C wants the Trust to acknowledge and apologise for failures in her son’s care and treatment and to make service improvements. She thinks a financial remedy is warranted in recognition of the distress she suffered.

8.D was 45 years old. He lived in supported accommodation, called Pathfinders, because of disabilities due to Alexander disease, which is a rare disorder of the nervous system. He needed full assistance with personal care and had a long-term catheter in place. On 16 November 2022, a urine sample was taken. The results showed D had a UTI caused by a bacteria called proteus mirabilis. The pathology report showed this was resistant to many antibiotics but was sensitive to an antibiotic called meropenem, which is given intravenously (IV). On 21 November, D’s GP spoke to a nurse at the care home. D had symptoms of UTI, including delirium. The GP noted the recent urine sample results and noted the proteus mirabilis was resistant to oral antibiotics.

9.As the GP believed he needed IV antibiotics as per the pathology report, and care home staff were unable to give residents IV medication, D’s GP referred him to hospital on 21 November so he could have IV meropenem. He had been admitted to hospital four times over the previous six months, with three of those because of UTIs.

10.An ambulance arrived at the care home at 11:15am. There was a delay of several hours at hospital, which meant he had to wait in the ambulance and the Trust’s Emergency Department (ED) recorded his arrival at 3:08pm.

11.D was admitted via ED. Doctors noted that his GP had requested IV meropenem but the hospital had not received written confirmation of the result from either the GP or pathology lab. They decided initially to try an oral antibiotic, fosfomycin. However, this was not available in the hospital at that time. D started becoming more unwell on the evening of 22 November and received a first dose of IV meropenem at 00:45 in the early hours of 23 November.

12.Sadly, D continued to deteriorate. At 4:30pm on 23 November, a doctor explained to Mrs C and D’s father that he was not responding to treatment and it was in his best interest to start end-of-life care. D was discharged back to the care home and died there on 30 November. The cause of his death was urosepsis.

18.Good Medical Practice says;

‘You must provide a good standard of practice and care. If you assess, diagnose or treat patients, you must adequately assess the patient’s conditions, taking account of their history (including symptoms and psychological, spiritual, social and cultural factors)…

Promptly provide or arrange suitable advice, investigations or treatment where necessary.’

19.It was noted on the ambulance record, ED record and during the post-take ward round (the first time a patient is reviewed by a consultant after being admitted to hospital) that the reason D’s GP sent him to hospital was for him to have IV meropenem. The laboratory results were made available on a system called SystmOne. As well as the GP Practice and Pathfinders, this was accessible to another local hospital, King’s Mill. However, it was not used at Bassetlaw. Doctors noted they had nothing in writing from the GP either.

20.The hospital team did not follow the GP’s request for IV meropenem, which at this stage had been passed on verbally via care home staff and the ambulance crew, but not confirmed in writing. The consultant who reviewed D when he was admitted discussed it with one of the Trust’s microbiologists. A microbiologist’s role within a hospital is to direct the prevention, diagnosis and treatment of infectious bacterial diseases. They provide a consultancy service to colleagues about the treatment of patients with infection or suspected infection. Although doctors were aware that D’s GP sent him to hospital for intravenous meropenem, we consider it was reasonable for the medical team to seek advice from a microbiologist rather than simply following the GP’s request, which had been passed on to them. It was in line with Good Medical Practice, which says ‘In providing clinical care you must… consult colleagues where appropriate’.

21.The microbiologist recommended fosfomycin rather than the IV meropenem. We consider this would have been reasonable to try. The record shows the microbiologist was aware that D’s proteus mirabilis in the July had not been resistant to fosfomycin as well as meropenem.

22.On admission, D did not show signs of being seriously unwell. The ambulance record describes him as ‘non-specifically unwell… during journey, patient alert/stable on route, talking ok, breathing OK, seemed comfortable with no pain expressed ’. D had shown signs of delirium at the care home, so was poorly but he appeared to be stable on admission and the clinical observations were satisfactory. His NEWS score was 2. (NEWS is a tool to detect clinical deterioration in patient and to indicate the response. It measures respiration rate, oxygen saturation, blood pressure, pulse rate, level of consciousness and temperature. A score of 2 would indicate 4 to 6 hourly monitoring but no urgent response action is required.)

23.Blood tests showed D’s CRP level to be 7.2, which is normal, with his white cell count slightly elevated at 14.9 (normal range 3.6 to 11.0). These two measures are markers of a possible infection and the body’s reaction to it. At this time, these levels did not suggest D’s infection was having a serious effect on him. As such, it may have been reasonable to try oral antibiotics as discussed with the microbiologist.

24.Our adviser says IV meropenem is generally for patients who are severely unwell. It is a potent drug, often used for serious infections where the infection has been resistant to conventional antibiotics. By limiting the use of this drug to selected situations, it is hoped that resistance to the antibiotic will not become prevalent.

25.Hospitals need to take account of the issue of antimicrobial resistance. (Antibiotics are a type of antimicrobial medication.) The World Health Organization (WHO) says Antimicrobial resistance (AMR) is one of the top global public health and development threats, with the main cause being the misuse and overuse of antimicrobials. This is reflected in the NICE guidance on antimicrobial stewardship, which says ‘When deciding whether or not to prescribe an antimicrobial, take into account the risk of antimicrobial resistance for individual patients and the population as a whole’.

26.Although there was no sign initially that D was severely unwell, he was still a high-risk patient; he had other significant health problems including type-2 diabetes, which increased the chance of infection. He had a long-term catheter in place, and renal stones, both of which increase the risk of infection. He had had several previous infections, which were resistant to several antibiotics. Furthermore, he was frail due to his Alexander disease. His GP clearly recognised he was at risk of deterioration and had an infection that needed treating promptly and one that was best managed in hospital given that he was showing some signs of becoming unwell and with a pathology result showing he was in need of IV antibiotics; he was reportedly more confused and the admission notes suggest that he may have had signs of delirium before he was admitted. The NHS website notes that infections, particularly UTIs can cause delirium.

27.While we consider it would have been reasonable to try fosfomycin initially, based on microbiology advice, the fact this was not available meant an alternative should have been considered immediately. Given D’s risk, doctors should have gone back to microbiology for further advice. We think it is reasonable to say the IV meropenem would have been advised as this drug would have been more immediately available (as it was later).

29.The medical team reviewed D with a consultant assessment (post-take ward round) on 22 November at 1.22pm. At this stage it was reported that he had been increasingly confused prior to admission and had pain on passing urine. The doctor noted that he had been in hospital during July with proteus mirabilis. The microbiologist’s advice was noted and the plan was continued. There was a request to repeat the urine culture and administer the oral fosfomycin with a working diagnosis of UTI and delirium. The blood tests that were reviewed were those from the day before. D had not had antibiotics at this stage. We have seen nothing in the records that doctors considered the consequences of a delay in treating the infection in a vulnerable patient.

30.At the next review later that day at 9.23pm, the doctor recorded that the fosfomycin still had not been administered. (‘Ward has been waiting for fosfomycin from pharmacy 2 days but currently out of stock.’) D was more unwell now with a fast heart rate of 150 beats per minute. A fast heart rate can be caused by infection. There was a plan to start IV meropenem and fosfomycin (once it arrived), but that this would need to be checked with microbiology.

31.The medication records show D was given an IV injection of meropenem of 500mg (the minimum dose recommended by the BNF) at 12:45am in the early hours of 23 November, which was over three hours later. So, even when D became unwell at 9.23pm on 22 November, there was a delay in giving him the IV meropenem and it was the minimum dose. Given he had arrived at hospital just before 3pm (when he was triaged in ED) on 21 November, this means it was around 34 hours before D had any sort of antibiotic. Mrs C spent time in hospital with her son and we have seen that she advocated for him. She spoke to a doctor on the afternoon of 23 November and expressed her unhappiness that D had not been given IV meropenem. The doctor explained the reason for trying fosfomycin first but there is no indication that they explained it had not actually been given to D.

32.The same doctor reviewed D a few hours later at 3:10am. His NEWS was now 8, which put him in a ‘high risk’ category. He had a respiratory rate of 24, temperature of 39.3, and heart rate at 187. The working diagnosis was urosepsis. Sepsis is a life-threatening reaction to an infection. If it starts in the urinary tract it is called urosepsis. Our adviser says this diagnosis was in keeping with those clinical signs; NICE NG51 says temperature, heart rate and respiratory rate, all of which were elevated at this time, should be assessed. The doctor calculated D’s NEWS was now 10. His blood pressure was low at 81/50.

33.The doctor’s plan included further IV meropenem. The medication chart shows the next dose of 1 gram was given at 10:21am. This was nine and half hours after the first dose was given, and about seven hours after the 3:10am review. D was now septic. We note the earlier dose should have been 1 gram, which is the maximum dose recommended by the BNF. This was at 00.45 and the dosing regime should be three times a day or every eight hours. This second dose was therefore delayed. We do not consider this was such a long delay as to make a significant difference; the more important issue is the overall delay in giving D any sort of antibiotic.

34.Despite having been started on IV meropenem, D rapidly deteriorated on 23 November and was placed on an end-of-life care pathway. The next day, he was discharged back to Pathfinders Care Centre, where he died a week later. The discharge notice said that he had been treated with fosfomycin. This statement was wrong.

35.NICE guideline [NG113], Urinary tract infection (catheter-associated): antimicrobial prescribing, 2018 says:

1.1.6 Offer an antibiotic… to people with catheter-associated UTI. Take account of: • the severity of symptoms • the risk of developing complications, which is higher in people with known or suspected structural or functional abnormality of the genitourinary tract, or immunosuppression • previous urine culture and susceptibility results • previous antibiotic use, which may have led to resistant bacteria.

1.1.7 When urine culture and susceptibility results are available: • review the choice of antibiotic and • change the antibiotic according to susceptibility results if the bacteria are resistant, using narrow-spectrum antibiotics wherever possible.

36.The guidance states that an antibiotic should be given to people with a suspected UTI before results are available. This is supported by the fact that the microbiologist advised to start fosfomycin. D’s symptoms were not severe on arrival, but it was known he was high risk and had previous infections. Even though there was no written communication from the GP or pathology laboratory, it was reasonable to assume he had a urinary infection given the message that care home staff had passed on about why he had been referred to hospital.

37.We found there was a failure by the Trust to provide treatment in a timely way, contravening Good Medical Practice requirements for doctors to ‘Promptly provide or arrange suitable… treatment where necessary.’

38.We considered what impact this had. Our adviser said the delay in antibiotic administration is more than likely to have contributed to D’s deterioration and death.

39.D had suffered frequent urine infections. The assumption when he was first admitted in November was that he had an infection caused by the same organism as the previous July. This was reasonable and was later confirmed. If fosfomycin had been available and given to D, or if they had started IV meropenem immediately, then the likelihood of him deteriorating would have been reduced, or if he had, the deterioration would not have been as severe.

40.On balance of probabilities we consider this was a lost opportunity to have given D treatment which we think more likely than not could have prevented him from developing sepsis; his death was avoidable. He had had the same infection in the past and had got better. We cannot see why this time would have been any different if antibiotics had been started in a timely way. He was not showing signs of sepsis when he arrived at hospital.

41.As it is, D arrived at hospital already with a confirmed diagnosis of a urinary tract infection. He had been referred by his GP in order to have this treated with IV antibiotics. He was high risk. Despite this, he was not given any antibiotics until around 34 hours after he arrived by which time he had already started to deteriorate. We recognise this was a very distressing time for Mrs C.

43.We therefore uphold the complaint.

1. We carefully considered Mrs C’s complaint about the care and treatment her adult son, D, received from Doncaster and Bassetlaw Teaching Hospitals NHS Foundation Trust.

2.We uphold this complaint. We find the Trust failed to treat D in a timely manner when he was admitted to hospital with an infection. This is likely to have contributed to his death. We recognise Mrs C’s priority has been for the Trust to acknowledge its role to understand the events leading to her son’s death and for any failing to be appropriately addressed. We hope our report provides this information and reassures her that appropriate recommendations will be made.

3.We recommend the Trust acknowledge its failing, apologise for the impact it had and take action to prevent a recurrence. We also recommend it pay Mrs C a financial remedy in recognition of the distress she has experienced due to the probable premature death of her son.