Tim Mason’s Story: Treating Sepsis Early is Vital

Recent research by BBC News shows that hospitals are still failing patients with sepsis and one quarter have to wait longer than the recommended one hour to be put on an antibiotic drip.

We work with the UK Sepsis Trust to help raise awareness of sepsis and prevent errors in diagnosis and treatment. So, we were proud to act for Tim Mason’s family and currently act for a number of other people who have lost relatives or suffered disability from errors in managing sepsis.

How are our hospitals doing?

The BBC’s research looked at reporting by hospitals over the last 3 years as to how well they spot and treat sepsis. One question is how quickly antibiotics are given. They should be given within one hour. This was done in only 75% of cases.

This is better than 3 years ago when the figure was only 40%. But some hospitals are better and some are worse – there are huge variations. In Wales, only 71% of patients were treated within an hour. Many patients are still being treated too slowly.

Read more: Sepsis: Is It on the Increase?

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 to actually see Tim.

None of them considered sepsis. Had they followed the hospital’s sepsis protocol they would have treated Tim with antibiotics and he 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 and 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.

Tim’s parents, Gavin and Fiona, have campaigned tirelessly to raise awareness of sepsis and recently spoke on BBC News. They feel that changes resulting in lives being saved would be of some small comfort.

WHAT IS SEPSIS?

Sepsis is the body’s overwhelming response to infection which causes 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 which develops rapidly. The chance of death increases by 8% per hour, meaning 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.

Read more: Sepsis – When Things Go Wrong

What are the signs of sepsis?

The signs of sepsis include:

  • Slurred speech
  • Shivering or muscle pain
  • Not passing urine
  • Breathlessness
  • Fast heart rate
  • Abnormal temperature
  • Mottled or discoloured skin (and this is often a sign of advanced sepsis)

 

EARLY WARNING SCORES

Early warning scoring systems have been developed to assist in alerting 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.

SEPSIS PROTOCOLS

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 him 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.

Read more: Sepsis – 6 Steps to Save a Life

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 very 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, so 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, but 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.

Considering Making a Sepsis Compensation Claim?

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 sepsis negligence solicitors today.

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