BackA 45-year-old man with disabilities could still be alive if he had been given antibiotics earlier, an Ombudsman investigation has found.
The father-of-two died after he was referred to hospital for intravenous (IV) antibiotics for a urine infection but had to wait 34 hours for the medication. By the time he received the antibiotics it was too late and he died from sepsis.
The Parliamentary and Health Service Ombudsman (PHSO) found that his death was avoidable.
The man lived in supported accommodation in Ollerton, Nottinghamshire, and had a rare, incurable disorder called Alexander’s Disease which affects the nervous system. He had respiratory and mobility issues and needed 24-hour care and help with feeding and personal hygiene.
Due to his condition, the man had a permanent catheter and was susceptible to Urinary Tract Infections (UTI). In November 2022, he contracted a UTI that was resistant to oral antibiotics and was referred by his GP to Bassetlaw Hospital for IV antibiotics.
His disabilities meant he had difficulties communicating with staff and raising the lack of treatment, and he was reliant on clinicians to give him the right treatment at the right time. His mother raised concerns about her son’s treatment with staff at the time but she was never told that he had not received the antibiotics he had been sent to hospital for.
This tragic case highlights issues in sepsis awareness and the importance of listening to patients and their families, particularly if a patient has difficulties communicating.
PHSO has repeatedly raised concerns around avoidable deaths and sepsis. Including reports in 2013 (Time to Act) and 2023 (Spotlight on Sepsis) that highlighted the same mistakes, such as delays in diagnosis and treatment, poor communication and record-keeping, and missed opportunities for follow-up care, were putting lives at risk.
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Source: The Parliamentary and Health Service Ombudsman, UK
