Tim Mason’s Story: Treating Sepsis Early is Vital
The tragic mistakes which led to a 21 year old man dying of sepsis show the importance of recognising sepsis early in our Accident and Emergency Departments.
Tim Mason’s story
Tim Mason attended his local Emergency Department at around 3.30 am on 16th March 2018 ‘feeling like death’ (as many people with sepsis say), with a raised temperature and a fast heart rate. He was seen by a triage nurse and a junior doctor. The junior doctor took advice from his registrar but the registrar failed actually to see Tim. None of them considered sepsis. Had they followed the hospital’s sepsis protocol they would have treated Tim with antibiotics. Tim would have got better. Instead they discharged him after 4 hours having infused 3 litres of fluid. The need for such a large amount of fluid should itself have suggested that Tim was in fact seriously ill.
Later that day Tim returned to Accident and Emergency. By then his organs were starting to fail. It was too late to save his life. Despite the best efforts of the hospital staff, he suffered a cardiac arrest and died.
The hospital’s medical director has apologised and said, he ‘will ensure that lessons are learnt by our doctors and nurses’. If any good is to come of these tragic events, it is important that lessons are in fact learned.
What is sepsis?
Sepsis is the body’s overwhelming response to infection which caused harm to tissues and organs. Tim was suffering from the W strain of meningitis. In fighting the infection his body in effect caused harm to itself. Sepsis is a very serious condition. It develops rapidly. The chance of death increases by 8% per hour. This means that time is of the essence. It is important to recognise sepsis early and intervene. That involves treating the underlying source of infection. In Tim’s case it meant treating bacterial meningitis with antibiotics. If may also mean supporting the body’s systems in the meantime and many patients have to be admitted to intensive care departments to do this.
Early Warning Scores
Early warning scoring systems have been developed to assist in altering hospital staff to deteriorating patients. Scores are given to different observations – such as temperature, blood pressure and heart rate. The score is then totalled. The arithmetic should be simple.
Tim’s early warning score when he arrived at the Emergency Department should have been 3. That should have triggered ‘inform nurse in charge, repeat observations in 30 minutes, request doctor review within 30 minutes’. Unfortunately during his triage the nurse failed to complete the ‘Sepsis Screen’ on the triage form.
Early Warning Scores are only part of the Sepsis Screening Process. Hospitals should have Protocols in place to guide doctors in treating patients. When Tim was seen by a junior doctor he had bloods taken which showed raised lactate. This can be a sign of sepsis. His various signs should have shown his to have ‘red flags’ of sepsis. He should have been treated with the ‘Sepsis Six’. This involves 3 tests and 3 treatments. The treatments include antibiotics, intravenous fluids and oxygen. The tests are blood samples, blood cultures and urine monitoring.
What can our Hospitals do better?
The hospital’s director has said that lessons will be learned. In fact hospitals have introduced Early Warning Scoring systems and have sepsis protocols in place. There are a lot of resources available to assist doctors in identifying sepsis early and managing it effectively. But it is still not always easy to recognise sepsis developing. So what can be done?
First, there needs to be a greater awareness of sepsis. Over recent years sepsis has attracted a lot of publicity. The UK Sepsis Trust (with whom we are proud to work) has been every effective in increasing public awareness. It is important that doctors and nurses, particularly in Emergency Departments, are alert to patients who may have sepsis. Hospital staff often work under a lot of pressure and it is easy to overlook things. Sepsis needs to be in the forefront of their minds. One thing the hospital has introduced is a reminder about sepsis at the foot of its emails.
Secondly, staff need to know about their own protocols. There is a mass of information available to us all the time and managing that information can be difficult. The same is true of hospital staff. This means the protocols must be readily available and highly visible.
Thirdly, they need to follow them. It is because our own judgements are not always as reliable as we think that we need to rely on systems. It still surprises me how many claims I am involved in where the information is available to clinicians but for some reason they fail to treat when they should. I have seen cases where nursing staff have correctly taken observations and entered details on a screening form. The Early Warning Score is rising but the sepsis protocols are not followed. Quite what the answer is here I simply do not know. The systems are there. They need to be followed.
In the meantime there is little that can help Tim’s family come to terms with their tragic loss. We can only hope the story highlights what can go wrong and helps to avoid others suffering the same loss.
Paul Sankey acted for Tim’s family at the inquest into his death and on their claim for damages. If you would like advice about a possible claim please get in touch with our friendly and experienced medical negligence solicitors today.