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Sepsis

Sepsis is a rare complication of any infection which can be from something as minor as a cut to the knee. Sepsis commonly occurs from Urinary Tract Infections, Pneumonia in the lungs and infections around the pelvis and abdominal regions.

Usually, your immune system localises infection, meaning that it keeps the infection limited to one place in the body. Your body produces white blood cells which can then travel to the isolated site of infection and attempt to destroy the germs which have caused it. If a person has a weakened immune system (perhaps due to a genetic disorder or possible disease (HIV)), or the particular infection is very severe, the body produces a limited about of white blood cells. This, in turn, will make it particularly difficult for the body to attack the infection and therefore the infection can take affect and spread rapidly. This results in a drop in blood pressure, ultimately stopping oxygen reaching the organs and tissues.

How Is Sepsis Diagnosed?

Sepsis can usually be diagnosed on simple measurements such as temperature, heart rate, breathing rate and blood tests. To determine the type of infection and what bodily functions have been affected, other measurements may need to be taken. These include; urine or stool samples, blood pressure tests, imaging studies such as x-rays, respiratory secretion testing (from the saliva, phlegm or mucus) and wound culture.

What Are The Symptoms Of Sepsis?

Unfortunately, Sepsis can initially look like flu, gastroenteritis or a chest infection. There is no one sign, and symptoms present differently between adults and children. This provides an explanation as to why so many cases, particularly in young children, go undiagnosed until it is too late.

The symptoms of sepsis in older children and adults can include a high temperature (fever) or a low body temperature, chills and shivering, a fast heartbeat and fast breathing. In some cases, confusion and no passing or urine can also be symptoms.

In young children, the symptoms can include being very lethargic or difficult to wake, feeling abnormally cold to touch, fast breathing and a rash that does not fade when you press it. They are also likely to be off their food.

Treatments And Prognosis

If caught early enough, sepsis can be treated with antibiotics and patients usually make a full recovery. Unfortunately, for those left undiagnosed, the infection can take affect extremely quickly which can lead to multiple organ failure and subsequently death. Often, if the infection has been left and there has been a delay in diagnoses, it will attack the extremities first. This can result in the need for amputation if there is no other alternative to stopping the infection from spreading.

Figures

BBC Panorama 11th September 2017- 37% of patients that need antibiotics are not getting them within the hour that they are required.
Sepsis Trust UK- 123,000 cases per year of which 44,000 are fatal. Raising awareness is thought to save around 14,000 of these lives.
Health Secretary Jeremy Hunt said to BBC Panorama: “There are preventable deaths happening but we’re bringing them down and I think that the picture is much improved from two years ago, but there’s a long way to go. Safety is at the top of the NHS’s in-tray… and sepsis is, if you like, a litmus test as to whether we’re getting there and I would say that what it shows is that we are making progress but there is a lot more work to do.”

Case Study - Sepsis

Mr V & Mrs N Adcock on behalf of the estate of Jack Adcock deceased -v- University Hospitals of Leicester NHS Trust

Background

Jack came home from school on the 17th February 2011 feeling unwell. During the evening of the 17th and early hours of the 18th February, he suffered with vomiting and diarrhoea.  On the morning of the 18th February, Mrs Adcock noticed Jack was having trouble breathing and his fingertips were blue.   He was seen by his GP at 9.30 am who noted he was drowsy and lethargic, his breathing was rapid and he was using his abdominal muscles to breath.  The GP was sufficiently concerned about Jack’s condition, to arrange urgent admission to the Children’s Assessment Unit at the Leicester Royal Infirmary (LRI).

Upon admission, Jack was noted not to be very responsive, limp, extremely lethargic with a grey tone to his skin.   He was immediately reviewed by the Paediatric Registrar who placed Jack on oxygen and fluids.  Jack underwent a chest x-ray and had bloods taken shortly after his admission at around 11.00 am.  Throughout the day, Jack had severe diarrhoea and the nursing staff experienced difficulties in obtaining his oxygen saturation levels due to his hands and feet being so cold.  These problems were brought to the attention of the Paediatric Registrar and when a reading was eventually obtained Jack was noted to be slightly tachycardic.  His respirations were high and he was apyrexial.  His blood gasses were taken on two occasions which showed he had severe metabolic acidosis.  The Paediatric Registrar informed Mr and Mrs Adcock that Jack had an infection but that they could not treat it straight away as they needed to know whether it was viral or bacterial.

The nursing staff continued to experience difficulties with obtaining Jack’s saturation levels and it was noted that measurements could not be obtained due to his peripheries being “cold and not well perfused”. At about 4.00 pm Jack was started on anti-biotic because his infection was bacterial.  Shortly after being given anti-biotics Jack vomited.  This was brought to the attention of the nursing staff.  Whilst Jack was being transferred to the Childrens Ward he vomited again into his oxygen mask.  The colour of the sick was red and Mr and Mrs Adcock were concerned that there was blood in Jack’s vomit.  The nursing staff put this down to him having had blackcurrant dioryalyte earlier.

At about 8.15 pm Jack became very drowsy and his lips turned blue. Mrs Adcock called for assistance and it appeared Jack was in cardiac arrest.  Resuscitation attempts were started but this was interrupted when the Paediatric Registrar came into the room and stated Jack was a DNR.  This was checked and it transpired the Paediatric Registrar had mistaken Jack for another child in the hospital.  The resuscitation attempts resumed but unfortunately without success and Jack died.  Mrs Adcock was present during the cardiac resuscitation attempts and Mr Adcock arrived shortly thereafter.

Criminal investigations into Jack’s death ensued with a view to bringing gross negligence manslaughter charges against the treating doctor and two of the nursing staff. It was clear there were severe failings in the treatment Jack received on the 18th February 2011.  Reports were obtained by the Police from experts in Paediatrics and Nursing, which confirmed severe breaches of duty in the care Jack received. However, as the Paediatrician advised there was a 10% chance Jack may not have survived even had the correct treatment been provided, the Police were not able to bring formal charges.  An Inquest was opened following the police investigations and the clinical negligence claim was pursued at the same time as representing the clients at the Inquest.

The Claim

A Letter of Claim was submitted to the Defendant Trust setting out the failures in Jack’s treatment both from the point of view the Paediatric Registrar and the nursing staff. Allegations against the registrar included a failure to arrange an intensive care review upon Jack’s admission which was mandatory given his condition, failure to recognise the severity of his condition and involve a Consultant Paediatrician in his management from the outset, delay in administering antibiotics which should have been prescribed at Jack’s presentation given his condition and lastly, asserting Jack was not for resuscitation, having mistaken him for another child in the ward.  Allegations against the nursing staff included a failure to recognise the severity of Jack’s condition and to escalate his care to a Paediatric Consultant, failure to properly document important clinical signs of Jack’s condition, failure to monitor Jack’s vital signs and fluid balance from 11.00 am to 7.00 pm and to document those observations, failure to escalate concerns to a more senior member of nursing staff.   It was alleged in the Letter of Claim that had Jack received the appropriate treatment he was entitled to he would have survived.  The Letter of Claim also included claims on behalf of Mr and Mrs Adcock themselves for psychiatric damages.

The Trust’s solicitors admitted breach of duty and causation for Jack’s death shortly before the Inquest was due to start in July 2013 and made an offer of in settlement of the Estate Claim. The Trust did not make any admissions to the psychiatric damage caused to Mr and Mrs Adcock and so reports were obtained from a Consultant Psychiatrist who confirmed that both Mr and Mrs Adcock had suffered psychiatric injuries as a result of the Defendant’s negligence.  Copies of these reports, together with Schedules of Losses were sent to the Defendant.  Following negotiations all three claims settled for a global five figure sum.

The Inquest

Given the Trusts admission of liability and causation days before the trial we applied for and got exceptional legal aid for the family to represent them at the inquest.   The Inquest into Jack’s death started on the 22nd July 2013 and was listed for 2 weeks.  On day 5 of the Inquest, whilst the Paediatric Expert was giving his evidence the Inquest was adjourned due to the expert confirming that had Jack been given the appropriate treatment he would have avoided the cardiac arrest which caused his death.

The Coroner adjourned the Inquest in order to allow the CPS to re-investigate and it is our understanding that the CPS sought a second report from a Paediatric Expert. In December 2014, the CPS advised that they were formally charging the Paediatric Registrar and two of the nurses involved in Jack’s treatment with gross negligence manslaughter.