‘Shambles’ as man dies from sepsis after 34-hour medication delay

The care given to a 45-year-old disabled man who died of sepsis after not being given the correct medication for 34 hours was described by his mother as “futile”.

The father-of-two, identified only as Graham, was admitted to Bassetlaw Hospital in Nottinghamshire in November 2022 with an infection.

An investigation by the Parliamentary and Health Service Ombudsman (PHSO) found that doctors did not follow the advice of the mother, care home staff or paramedics to give him intravenous (IV) antibiotics rather than orally because this was not confirmed in writing.

The report concluded that his death could have been avoided and he might have been alive if he had been given the correct intravenous antibiotics earlier.

His mother Sylvia, who asked that only first names be used, said Graham, who lived in Ollerton in Nottinghamshire, suffers from an incurable condition called Alexander disease, which affects the nervous system.

Frequent infections meant he was treated regularly at Doncaster and Bassetlaw NHS Foundation Trust, and although oral antibiotics were ineffective, he responded to intravenous medications.

PHSO's investigation found that despite an email sent by the GP (which remained unseen) and verbal advice, hospital staff during the last hospitalization decided to try an oral antibiotic, but the drug requested was not available.

The intravenous antibiotic was not given until 34 hours after Graham arrived at the hospital, and at half the dosage it should have been.

The report also states that there was a three-hour delay between the doctor requesting the medication and its administration.

By the time the second dose of antibiotic was administered, which was also delayed, Graham had become septic. He died a week later.

Sylvia said: “Everything was a mess. I spoke with the staff several times, but they fired me. He was not cared for for 34 hours.”

“I was under the impression that he was at least given antibiotics, even if they were the wrong ones.

“But to find out that he was in the hospital all this time without treatment was very difficult.

“They had a responsibility to look after him, they were professionals, but in the end he didn't stand a chance.”

The PHSO can be contacted by anyone who is unhappy with how organizations such as the NHS have handled their initial complaint.

CEO Rebecca Hilsenrath K.S. stated: “Losing life due to sepsis should not be inevitable.

“But we see the same shortcomings repeating again and again, and the number of sepsis complaints has more than doubled in the last five years.

“We also see poor communication between patients and doctors and we are focusing our efforts on helping to improve this across the NHS.”

Sylvia confirmed she had received a written apology, which she described as a “standard letter”, but had not seen the action plan the trust was ordered to provide.

Karen Jessop, the trust's chief nurse, said: “We are truly sorry for what happened in this case and the loss suffered by the patient's family.

“We have reviewed the information and assistance provided at that time through our patient safety team.

“Immediate action has been taken to strengthen the process for prescribing, escalating and administering antibiotics.”