Hull University Teaching Hospitals NHS Trust

7. Mrs K complains about aspects of the care and treatment provided by Hull University Teaching Hospitals NHS Trust (the Trust) to her father, Mr L between 10 July 2023 and 11 July 2023. She says:

• there was a delay before Mr L was seen by an ED doctor • the Trust was late to diagnose and treat Mr L for sepsis • the Trust failed to assess or treat Mr L’s heart murmur.

8. Mr L sadly died on 11 July 2023. Mrs K believes that earlier diagnosis and treatment may have given her father a better chance of survival and potentially avoided his death. Mrs K says this had caused her and her family emotional and physical distress and she is concerned about going to the same hospital. It has also led to financial hardship for the family.

9. To resolve her complaint, Mrs K would like the Trust to acknowledge its failings. She also seeks service improvements at the Trust, for lessons to be learned and action taken to ensure these events do not happen to anyone else in the future. She is also seeking a financial remedy.

10. On 10 July 2023, Mr L felt unwell and attended his GP practice. He had been suffering with stomach and kidney pains and had been sick.

11. The GP diagnosed Mr L with a urinary tract infection (UTI), a heart murmur and possible abdominal aortic aneurysm (AAA). This is a bulge in the part of the largest artery (aorta) that runs through the abdomen.

12. The GP wrote a referral letter and advised Mr L to attend the ED. The letter stated, ‘referred to ED to check kidneys, exclude AAA and treat UTI and further investigation if needed.’

13. Mr L attended the Trust’s Emergency Department (ED) at 3.49pm and provided the referral letter. A senior nurse triaged him and classified him as an ‘urgent’ category 3 patient with a serious illness but in a stable condition. A range of investigations were carried out, including blood tests and an ECG.

14. Later than evening, a doctor assessed Mr L. The working diagnosis at that time was pyelonephritis, which is an infection of the kidney and urinary tract.

15. In the early hours on 11 July 2023, Mr L was given intravenous antibiotics and fluids. The ED team arranged his admission to the AMU for further investigation of his heart murmur and continued treatment.

16. Mr L appeared to respond well to the treatment until the early morning when his condition deteriorated.

17. On 11 July, Mr L struggled to breathe after returning from the bathroom. Sadly, at 3.15pm he went into cardiac arrest and died.

21. Mrs K complains there was a delay before an ED doctor saw her father and the Trust was late to diagnose and treat her father for sepsis.

22. On 10 July 2023 at 3.49pm, Mr L attended the ED after his GP diagnosed him with a UTI and high heart rate. He was assessed by a senior nurse at 3.53pm and triaged as an ‘urgent’ category 3 patient.

23. The RCEM guidance explains that triage is a system of prioritising patients, according to a combination of their presenting complaint and their measured physiological observations when they arrive in the ED. The Manchester Triage System (MTS) is used within most EDs nationally and applied here.

24. According to the MTS, Mr L who was triaged as a category 3 patient, should have been assessed within 60 minutes. The evidence shows there was a significant delay of over six hours before Mr L was assessed by a clinician at 10.10pm.

25. Following his triage, a nurse requested that Mr L’s observations, bloods and an ECG be taken. The ED team also organised for Mr L to have several investigations including a full blood count, urea and electrolytes, liver profile, bone profile and C-reactive protein (CRP) levels. CRP is a protein the liver releases into the bloodstream when there is inflammation in the body.

26. The RCEM guidance explains that if there is a concern about the possibility of abnormal physiology, patients should have observations performed and an appropriate Early Warning Score (EWS) calculated, ideally within 15 minutes of arrival in the department.

27. The National Early Warning Score (NEWS2) system is a standardised method used to identify patients at risk of serious clinical deterioration. NEWS2 measures six parameters of vital signs in patients and is used by clinicians to calculate a score and level of clinical assessment based on the following parameters:

• A low score (1–4) should prompt assessment by a competent registered nurse or equivalent • A single red score (3 in a single parameter) is unusual, but should prompt an urgent review by a clinician • A medium score (5–6) is a key trigger threshold and should prompt an urgent review by a clinician • A high score (7 or more) is a key trigger threshold and should prompt emergency assessment by a clinical team.

28. The records show Mr L’s observations and EWS was recorded at 7.35pm, several hours after he was triaged. His score indicated he had an elevated heart rate and a combined EWS of 3 requiring prompt assessment by a competent registered nurse or equivalent.

29. A doctor assessed Mr L at 10.10pm, several hours after identifying he was a risk of clinical deterioration. The doctor noted a systolic murmur was heard on examination, this is an unusual sound when the heart contracts and pumps blood out to the body. The working diagnosis was pyelonephritis, an infection of the kidney and urinary tract. NICE guideline NG111 recognises sepsis as a possible serious complication of pyelonephritis.

30. Mr L’s test results showed he had a significantly raised white blood cell count and CRP level and a mildly raised lactate level of 2.0 mmol/L. These results indicated an acute infection and potentially early sepsis.

31. Several hours later at 1.08am on 11 July 2023, Mr L received treatment consisting of intravenous cefuroxime antibiotics and fluids. This was several hours after his assessment with a clinician.

32. Our ED Adviser says when Mr L was assessed at 10.10pm, a working diagnosis of pyelonephritis was appropriate. Mr L was at moderate risk of sepsis. NICE guideline NG51 (sepsis recognition) says patients with suspected sepsis should be given intravenous antibiotics within one hour of identifying that they meet any high risk criteria, for example, a raised heart rate of 91 to 130 beats per minute. Mr L’s heart rate was 115 beats per minute.

33. We currently think Mr L should have received antibiotics sooner and this should have been completed within one hour of identifying he was at risk of developing sepsis.

34. Mr L was then transferred to the AMU for further investigation and treatment. On admission, he was suspected to have sepsis. At 2.20am, his EWS was 0, suggesting that his vital signs were improving with intravenous antibiotics and fluids.

35. Although Mr L initially showed signs of some improvement, by early morning his condition had deteriorated.

36. At 6.04am, Mr L’s EWS score was 7, indicating he was at severe risk of clinical deterioration. He had a raised heart rate of 150 beats per minute and an elevated respiratory rate of 25 breaths per minute. NEWS2 guidance states a high score of 7 or more should prompt an emergency assessment by a clinical team.

37. Mr L met two high-risk criteria for sepsis as set out in NICE Guideline NG51, with a raised respiratory rate of 25 breaths per minute or more and a heart rate above 130 beats per minute. Mr L should have had the following interventions:

• immediate review by a senior clinical decision maker • repeat lactate measurement • consider prescribing gentamicin • his care discussed with a consultant • observations every 30 minutes.

38. Although Mr L was given cefuroxime antibiotic, gentamicin is a broad-spectrum antibiotic used to treat severe bacterial infections. In the management of sepsis, it is often administered in combination with cefuroxime to provide treatment against bacteria.

39. Our Physician Adviser says a review should have resulted in further investigations including a repeat ECG and blood gas test to check his lactate level. We have seen no evidence to show that Mr L had a repeat blood gas test to check his lactate measurement when his EWS was 7.

40. NICE guideline NG51 states adults with suspected sepsis who meet any high risk criteria and have a lactate level over 4 mmol/litre, should be referred to critical care for review and management.

41. A lactate measurement taken later that afternoon at the time of his cardiac arrest subsequently confirmed an elevated level of 10.2 mmol/L.

42. We think based on the balance of probabilities because of the lactate level taken later, this would have indicated Mr L would likely have had a raised lactate level above the threshold earlier.

43. We think the Trust failed to promptly escalate and initiate an emergency assessment by the clinical team and this resulted in a missed opportunity to consider transferring Mr L to critical care for sepsis management.

44. NICE guideline NG51 states people with suspected sepsis who meet any high risk criteria should be monitored continuously, or a minimum of once every 30 minutes. Although the records show a further set of observations was taken within 30 minutes, this level of monitoring was not maintained in accordance with NICE guideline NG51.

45. Without monitoring, changes in vital signs such as low blood pressure, falling oxygen levels or rising heart rate could go unnoticed, potentially delaying critical treatment until the patient becomes seriously unwell.

46. At 9.06am, Mr L was given a second dose of intravenous cefuroxime antibiotics as prescribed.

47. At 10.14am, a doctor assessed Mr L. His blood test results showed he had an elevated white blood cell count and a significantly elevated CRP, indicating an infection, the potential source being a kidney infection. When the doctor assessed Mr L, his lactate had not been repeated and was unknown. The doctor recommended further investigations including bloods, ECG and gentamicin if required.

48. At 11.01am, Mr L’s NEWS2 score had improved to 2, but his blood pressure was still falling. Our Physician Adviser says that if he had received close medical attention, a doctor would likely have recognised this as a sign of sepsis, treated him with intravenous fluids and considered further antibiotics, primarily a single dose of gentamicin. We have seen no evidence Mr L was given gentamicin.

49. We know that Mrs K is concerned that the Trust prescribed her father intravenous co-trimoxazole antibiotic to be taken twice a day and this medication was never administered. Our Physician Adviser told us there is no obvious evidence that this caused harm to Mr L as he was administered intravenous cefuroxime.

50. Our view is that the Trust did not follow the MTS guidance and assess Mr L in the ED within the 60 minute timeframe.

51. Our view is that the Trust did not adhere to NICE guideline NG51. Specifically, there was a failure to administer antibiotics within the recommended timeframe. The evidence also indicates there was a failure to monitor his observations continuously or at 30 minute intervals and the Trust failed to conduct an emergency assessment when he showed signs of clinical deterioration.

52. Our Physician Adviser says Mr L had sustained a type 2 myocardial infarction which is a heart attack that is provoked by the stress on the body from sepsis, as opposed to a problem primarily with the heart itself. This happens due to the reduction in blood pressure and widening of the blood vessels due to sepsis.

53. We have considered the likely impact on Mr L in detail, considering the various care and treatment failings we have identified.

54. A study by Ferrer et al. (2014) found that starting antibiotics within the first hour gives the best chance of survival, but even then, about 25% of patients may not survive. Waiting two to three hours can increase the chances of survival slightly, although the risk of death would still be significant.

55. Mr L had several co-morbidities including high blood pressure, a previous heart attack, pre-diabetes and a history of cancer requiring removal of his bladder and prostate. A study by Scott et al. (2008) states that the presence of pre-existing cardiac disease is associated with around a three-fold increase in mortality risk in sepsis. Taking into account his co-morbidities, particularly pre-existing heart disease, he was more likely to die than not.

56. We cannot say Mr L’s death would have been avoided because sepsis with bacteria in the blood is associated with a significant risk of mortality even with optimal treatment. What we can say is that there is a remote chance Mr L’s death could have been avoided if his care had aligned with NICE guidance NG51.

57. Mrs K will never know whether her father would have survived, and this is an injustice to her and a cause of considerable distress. When discussing the potential failings in her father’s care, Mrs K explained that she had serious concerns about the quality of care the Trust would provide to her in the future, and that these concerns were adding to the distress she was experiencing.

58. We can see the Trust has recognised there was a delay in ED before Mr L was assessed by a clinician, a delay in administering antibiotic treatment and performing tests. Our complaint standards state action should be taken to make sure that learning is identified and used to improve services. Whilst the Trust has apologised and undertaken some steps to train and raise staff awareness, it has not demonstrated how the learning identified has been effectively embedded into service improvement in accordance with the complaint standards, and we make recommendations at the end of this report.

Heart murmur

59. Mrs K complains that the Trust failed to assess or treat her father’s heart murmur.

60. Mr L had a history of ischaemic heart disease. This is a disease of the blood vessels supplying blood to the heart muscle, generally caused by ‘furring up’ due to age, high cholesterol and other risk factors. Mr L suffered a heart attack in 2015, and it was identified a single coronary heart blood vessel was diseased.

61. The records show Mr L had an ECG performed in the ED. Our Physician Adviser says an echocardiogram (a scan of the heart) is not routinely performed in the ED.

62. NICE guidance for heart valve disease (NG208) recommends offering the patient urgent specialist assessment if valve disease is suspected. This should include an echocardiogram within two weeks.

63. After Mr L was transferred to the AMU, he had another ECG performed. The main finding was sinus tachycardia, meaning a fast heart rate.

64. Our Physician Adviser told us while there were some minor changes, these did not indicate the need for an urgent referral to cardiology and were likely related to the fast heart rate caused by the effects of sepsis on his body.

65. The ED records show that on examination, Mr L had a systolic murmur. There was no suspicion of a heart valve infection (endocarditis). Our Physician Adviser says a systolic heart murmur in this situation would often be due to a ‘flow murmur’, a noise heard in the context of ‘hyperdynamic’ circulation due to the effects of the sepsis on blood flow.

66. When Mr L was on the AMU, the doctor assessing him did not record a heart murmur on examination. Our Physician Adviser says if Mr L had survived and the heart murmur had been noted to have persisted during the admission then a non-urgent outpatient echocardiogram could have been arranged in line with NICE guideline NG208.

67. While in the AMU on 11 July, the nursing team also checked Mr L’s troponin level, which can indicate damage to the heart. The results showed an elevated level. Our Physician Adviser told us Mr L’s troponin level of 53 ng/L was slightly raised, but not significantly so. Patients with pre-existing heart disease, often have slightly elevated levels around 20-50 ng/L.

68. Mr L was assessed by a doctor who requested a cardiology review and beta blocker medication to slow his heart rate down. The records show this medication was administered.

69. Our Physician Adviser says it was appropriate to do a troponin level and then repeat this test prior to considering cardiology input. A second troponin test was performed, however, this result was not available until after Mr L had sadly died.

70. Our view is that clinicians provided care that aligned with NICE guideline NG208 and there was no indication for Mr L to have an echocardiogram or be urgently reviewed by cardiology.

1. Mrs K complains about the care and treatment provided by the Trust to her father, Mr L between 10 July 2023 and 11 July 2023. Mr L very sadly died in the early afternoon on 11 July 2023. We extend our condolences to Mrs K and her family and recognise these events continue to cause them significant upset and distress.

2. We have identified two failings in Mr L’s care following his arrival in the Emergency Department (ED) and transfer to the Acute Medical Unit (AMU). There was a delay before Mr L was assessed by a clinician in the ED and the Trust delayed in diagnosing and treating him for sepsis. We consider these failings caused additional and avoidable distress to Mrs K at an already difficult time.

3. We have seen no evidence the Trust took appropriate, urgent action in line with guidance, when Mr L was at risk of clinical deterioration. We think these failures denied Mr L the care and treatment he should have received.

4. We have found the Trust correctly assessed and treated Mr L’s heart murmur. We will not uphold this part of the complaint.

5. The evidence shows that whilst we think there were some failings in the care provided, appropriate and timely treatment would not have guaranteed improvement or survival. On the balance of probabilities, we cannot say that he would have survived even if his treatment had been optimal, but his chances of doing so would have been improved.

6. We will partly-uphold this complaint and have outlined the recommendations we will make at the end of this report. These include an apology, service improvements and a financial remedy.