Worcestershire Acute Hospitals NHS Trust

5. Mr O complains about the care and treatment the Trust provided his wife, Mrs O, between 1 and 3 May 2023.

6. Specifically, he complains the Trust missed multiple opportunities to diagnose and treat Mrs O’s neutropenic sepsis.

7. Mr O believes the Trust’s failure to diagnose and treat Mrs O for neutropenic sepsis earlier led to her premature death. As a result of the Trust’s actions Mr O says their four young children lost their mother, and he lost his best friend and wife earlier than they otherwise would have.

8. Mr O is seeking a financial remedy.

9. Mrs O was in her early 40s and had metastatic (cancer spread from original source to other areas) breast cancer since August 2021.

10. She also had earlier admissions with neutropenia (abnormally low levels of neutrophils in the blood) and fever. Neutropenia can be a side effect of chemotherapy. She required antibiotics and dose reductions of her chemotherapy.

11. The Trust admitted Mrs O to the acute oncology team on 1 May 2023 due to her feeling generally unwell, having a reduced oral intake, vomiting, and fatigue. At the time of her admission, Mrs O was on fourth line chemotherapy. This is treatment when three prior treatments have failed or become ineffective.

12. Mrs O deteriorated overnight and throughout the day on 2 May. Sadly, she died of neutropenic sepsis at 12.20am on 3 May.

1 May

16. Mr O complains the Trust missed multiple opportunities to diagnose and treat Mrs O’s sepsis.

17. In its complaint response, the Trust said it did not, initially, consider neutropenic sepsis. It acknowledged it should have considered giving intravenous antibiotics at that stage and so there was a missed opportunity here.

18. It also said it did not administer the first dose of antibiotics until 1.5 hours after escalation on 2 May. It apologised and made service improvements.

19. NICE guidance recommends diagnosing neutropenic sepsis in patients having anticancer treatment whose neutrophil count is 0.5 x 109 per litre or lower and they have either:

• a temperature higher than 38°C or • other signs or symptoms consistent with clinically significant sepsis.

20. Neutrophil count measures the number of neutrophils, a type of white blood cell, in a person’s bloodstream.

21. RCP NEWS guidance says a NEWS (an assessment system that combines blood pressure, temperature and other observations primarily) score of:

• 0 - 4 is considered low clinical risk • 5 - 6 is considered medium clinical risk, requiring urgent response • 7 or more is considered high clinical risk, requiring urgent or emergency response.

22. It also says clinicians should suspect sepsis in patients with a NEWS score of five or more, with a known, suspected or high risk of infection. These factors should lead to rapid escalation of clinical care, confirmatory investigations, and urgent treatment.

23. RCP NEWS additional guidance says when a patient in hospital has a NEWS score of five or six, the registered practitioner should urgently inform a clinician competent in the assessment of acutely ill patients.

24. Mrs O attended the Trust on the evening of 1 May 2023. A health care assistant on the acute oncology team assessed her. Her NEWS score was five. This prompted an assessment by the nurse in charge who reassessed Mrs O’s NEWS score to four.

25. Our adviser has helped us understand, the notes show Mr O did not have a fever, her neutrophil count was 0.9 and she had, after review, a NEWS score of less than five. Based on the NICE and RCP guidance above there were no indications to treat neutropenic sepsis.

26. Our adviser explained there is evidence in the records from 1 May which says Mrs O had significant anaemia, dehydration and impairment of her kidney and liver function. Our adviser has considered if these factors would have changed Mrs O’s care and treatment.

27. Considering the above evidence about Mrs O’s symptoms (including her history of breast cancer and recent 4th line chemotherapy), our adviser explained some clinicians may have administered antibiotics whilst waiting for blood results, but this is not essential or something that is in the guidelines above.

28. Our adviser is clear that even if antibiotics were administered on 1 May, it would have made no difference to the sad outcome for Mrs O.

29. We recognise the Trust found through its own investigations that there was a missed opportunity to administer antibiotics as a precaution on 1 May. After seeking advice from our adviser, and considering all the other evidence, we have determined the Trust acted in line with the guidelines in the care it provided on 1 May.

30. While some clinicians might have given antibiotics on 1 May, there is no evidence in Mrs O’s symptoms and results to show the Trust should have diagnosed sepsis according to the guidelines.

31. As such, we have not found a failing here.

2 May

32. Mr O says on 2 May, when he arrived at the Trust to see Mrs O, he was shocked to see her in and out of consciousness and had no idea she would deteriorate so quickly overnight.

33. On 2 May at 9.37am, the notes show Mrs O was ‘alert and orientated’ during observations, but it is documented she had a NEWS score of five.

34. NICE guidance for sepsis says administer the first dose of antibiotics within one hour of recognition or presentation of sepsis, or suspected sepsis.

35. The notes show the following observations from the medical records:

• 10am, further observations taken and NEWS score of five • 10.07am, reviewed by doctors, Mrs O felt ‘wiped out’ and in pain. She was diagnosed with neutropenic sepsis • 12pm, antibiotics were administered • 1.36pm, Mrs O was deteriorating with a NEWS score of 11.

36. The nurse who conducted the observations at 9.37am documented a NEWS score of five but did not escalate this to a doctor. RCP NEWS guidance requires urgent escalation of NEWS scores of five and above to a doctor.

37. We find that this omission by the nurse caused a 30 minute delay in identifying the signs of sepsis and diagnosing it.

38. The doctor conducted a ward round at 10.07am and eventually diagnosed Mrs O with sepsis.

39. This means, the doctor administered antibiotics 2.5 hours after there should have been a clinical suspicion of sepsis, therefore a delay of 1.5 hours. This is not in line with the NICE and RCP guidance above.

40. We have found there was a failing in escalating the NEWS score on 2 May and delay in administering antibiotics.

42. We go on to consider the impact of this.

Impact

41. What happened left Mr O understandably shocked and distressed. He told us that on 1 May doctors said antibiotics and fluids would ‘get her back up and running’, but they could not identify the source of infection. He went home believing she would be okay.

42. Her sudden and unexpected decline caused significant emotional distress, compounded by questions about whether earlier action might have prevented or delayed it. We are deeply sorry for the distress these events caused Mr O. Our contact with him shows this was a very difficult time with a significant emotional impact.

43. We also recognise the emotional toll of not being able to be fully prepared for Mrs O’s rapid deterioration, which denied her children the opportunity to say their goodbyes.

44. Mrs O had just celebrated her youngest son’s birthday the day before her admission to hospital. Her children thought she was generally unwell and attending hospital for a routine visit. Unfortunately, their mother never came back after her sudden deterioration.

45. Our adviser considered whether the failings we found had any clinical impact and advised that earlier antibiotics would not have improved Mrs O’s comfort.

46. Her comfort depended on pain control, intravenous fluids for dehydration, anti-nausea medication, and catheter comfort. Records show she received these treatments.

47. Our adviser also considered whether the outcome could have been different. By 1 May, Mrs O had multi-organ failure, including bone marrow failure, anaemia, and reduced platelets and white blood cells due to chemotherapy.

48. She also had significantly reduced kidney function and signs of liver failure. Our adviser told us, in this context, sepsis carries a very high mortality rate. Based on this, we found earlier antibiotics would have been unlikely to have changed the outcome.

49. Although earlier diagnosis and treatment would not have changed the outcome or extended her life, we find the delays left Mr O with uncertainty on whether her death could have been delayed. This uncertainty has added to his distress at an already difficult time.

50. We next considered what the Trust has already done to put right the impact of the failings we have found.

51. The Trust has apologised and acknowledged failings in the delay in diagnosing and the treating neutropenic sepsis on 2 May. It has explained it has provided more training for nursing and medical staff, and feedback has been provided to those involved in Mrs O’s care.

52. We appreciate the Trust sharing this with Mr O and being open and honest about the actions it has taken because of its failings. While these are important improvements, they do not appear to fully acknowledge the emotional impact of the failings.

53. We set out our recommendations below.

1. We have carefully considered Mr O’s complaint about Worcestershire Acute Hospitals NHS Trust (the Trust). We recognise the incredibly difficult experience Mr O and his family have been through, and offer our sincere condolences for the loss of his wife.

2. We have not found failings in relation to the care and treatment the Trust provided on 1 May. We do not think this was a missed opportunity to diagnose and treat neutropenic sepsis. This is life threatening sepsis in a person with low white blood cell (neutrophil) count.

3. We have found failings in the Trust’s delay in diagnosis and treatment of neutropenic sepsis on 2 May. Whilst we have not found this failing could have changed the sad outcome for Mrs O, we have found this caused Mr O distress and impacted on his bereavement.

4. For this reason, we partly uphold Mr O’s complaint. We set out our recommendations at the end of this report.

54. We make recommendations in line with our Principles for Remedy which say public bodies should acknowledge failures, apologise, make amends, and use the opportunity to improve their services.

55. The Principles say we aim to ensure the public body puts the complainant back in the position they would have been in had nothing gone wrong. If that is not possible, the public body should compensate them appropriately.

56. Our Principles for Remedy are reflected in the NHS Complaints Standards which say organisations should offer fair remedies to put things right and identify learning and use it to improve services.

What we found

57. Through investigating Mr O’s complaint, we found the Trust did not appropriately diagnose or treat Mrs O in a timely manner on 2 May, which caused Mr O and his family avoidable distress.

58. The Trust’s actions have left Mr O with the uncertainty of knowing if his wife would have lived longer. This has added to the family’s distress and bereavement process.

What the organisation should do

59. Our Principles for Remedy say organisations should acknowledge poor service and take steps to put things right when this leads to an injustice or hardship.

60. As the Trust have already apologised for the failings we have seen in relation to diagnosing and treating sepsis on time, we would not ask it to repeat this.

61. We recognise Mr O seeks financial remedy for the loss of his wife. As set out above, we have not linked the failings to her death and so we cannot make a recommendation for bereavement for the loss of his wife.

62. However, we have considered financial remedy for the distress and uncertainty Mr O experienced due to the failings we have seen.

63. Our Principles for Remedy say organisations should compensate people appropriately if they cannot return the person affected to the position they would have been in if the poor service had not occurred.

64. To decide on a level of financial remedy, we review similar cases where the person has experienced a similar injustice, along with our severity of injustice (SOI) scale.

65. Level three emotional injustices on our SOI scale includes distress, worry, or inconvenience usually experienced over a significant period of time. This includes emotional distress experienced during the bereavement process.

66. We consider Mr O’s injustice sits within level three on the scale.

67. Therefore, following this review, we recommend the Trust pays Mr O £700 in recognition of the distress and uncertainty he experienced and the impact this had on his bereavement.

68. The Trust should send us evidence it has done this within a month of our final report.

69. We recognise these events have been distressing for Mr O, following the loss of his wife. We thank him for bringing this complaint to us.