Failures By Hospital Led To Avoidable Sepsis And Death Of Woman

It has been reported this week that the Public Services Ombudsman has found that failures by doctors at Princess of Wales Hospital to diagnose a woman’s ruptured appendix led to her death.

The Ombudsman, who investigated concerns about the woman’s death, said that the 49-year-old woman died from sepsis that could have been avoided.

The investigation by the Ombudsman was into the treatment of a 49-year-old woman, referred to as “Mrs F” in the report, who died in August 2020. She went to the emergency surgical unit at the Princess of Wales Hospital in July 2020, and again three days later, but the staff failed to diagnose and treat her appendicitis.

In August 2020, Mrs F tragically died of sepsis induced by a ruptured appendix.

The Ombudsman’s investigation found that there was “no evidence that appendicitis was even considered as a potential diagnosis”.

The clinical adviser to the Ombudsman advised that “categorically the approach was inadequate.”

It was concluded by the Ombudsman that if Mrs F’s appendicitis had been identified and treated, her death could have been avoided.

The Chief Executive of the hospital’s health board said:

What is sepsis?

Sepsis is a life-threatening reaction to an infection. It happens when the immune system overreacts to an infection and starts to damage the body’s tissues and organs.

Sepsis is a leading cause of death in the UK, with a reported 44,000 cases every year.

Successfully managing sepsis requires prompt recognition, appropriate interventions to identify and control the micro-organisms and restore oxygen delivery to tissues, and appropriate escalation and decisive medical management within the first hour of red flag symptoms.

Sepsis needs treatment in a hospital immediately, because it can get worse very quickly. A patient should receive antibiotics within 1 hour of arriving at the hospital. If sepsis is not treated early, it can turn into septic shock and cause the patient’s organs to fail.

Early detection of sepsis is critical, as a delay in antibiotic treatment has been documented to result in increased mortality rates.

Comment

Most people will make a full recovery from sepsis if it is identified and treated appropriately early, but the case of Mrs F highlights the importance of clear and effective medical management.

The case of Mrs F is devastating, as it is clear that there was a complete failure to consider appendicitis as a potential diagnosis, thus leading to sepsis developing and ultimately resulting in this woman’s death.

Had she been diagnosed and treated promptly, her death would have been entirely avoidable.

It is vital now that this hospital works to bring into place the recommendations of the Ombudsman to ensure patient safety is a top priority and absolutely everything possible is done to ensure this doesn’t happen to anyone else.