Early warning signs missed as woman being cared for at home dies

Early warning signs missed as woman being cared for at home dies

Early warning signs missed as woman being cared for at home dies

Derbyshire Community Health Services trust concedes it could have done more

The 71-year-old died as a result of sepsis in her urinary tract.

A failure to spot early warning signs led to an elderly woman dying a week after she was admitted to hospital.

Details of the case were revealed by the Derbyshire Community Health Services (DCHS) NHS Foundation Trust.

A trust report states that the 71-year-old patient, renamed as Sheila to maintain confidentiality, “may have received life-saving treatment sooner” if “red flags” were spotted and assessed accordingly.

Sheila, who lived alone in the outskirts of Derby, died as a result of sepsis in her urinary tract.

Sepsis is a life-threatening condition caused by the body attempting to combat infection in an “abnormal” manner.

Staff at the trust will now be taken through mandatory sepsis training and will be given new devices to better keep track of the amount of oxygen in a patient’s blood – which would flag up early warning signs.

These devices, called pulse oximeters, could cost £30 per employee – £45,000 overall.

The trust’s report says that, for sepsis: “If recognised and treated early, patient outcomes are favourable, however sepsis can cause multiple organ failure, septic shock and death and is a common cause of admission to hospital.”

Meanwhile, a new scheme will be introduced by the trust to ensure staff assess all six of the main clinical observations – which could also flag up early warning signs and help prioritise patients.

The six key clinical observations are: Respiratory rate, oxygen saturation, blood pressure, pulse, temperature and conscious level.

The report says: “In Sheila’s case, the finding of a low temperature would have triggered her community matron to complete a sepsis screening assessment which may have alerted her to additional signs and symptoms, so-called ‘red flags’, suggestive of sepsis.

This 3D illustration shows rod-shaped sepsis bacteria in blood with red blood cells and leukocytes(Image: Getty)

“If any red flags were detected at the time of the assessment, Sheila may have received life-saving treatment sooner.”

Sheila had one adult son, who lived nearby, and she had been widowed for 10 years.

She was in poor health, having experienced a stroke two years previously and was dependent upon carers who visited three times each day.

Sheila was overweight, suffered arthritic pain and was unable to leave the house due to mobility issues.

She received care regularly from the DCHS diabetes specialist nurse, the community matron and the community nursing service.

Her diabetes was becoming “difficult to control”, she was becoming “increasingly depressed” and she had “extremely swollen” legs due to worsening lymphoedema – a long-term condition that causes swelling, typically in the arms or legs.

The report says that Sheila’s health status placed her at high risk of severe infection.

Sheila was seen by her GP towards the end of April 2017 at the request of her community matron.

This was due to recent episodes involving low blood sugar levels and subsequent changes to her insulin prescription.

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Sheila’s temperature, blood pressure and pulse were all within normal limits.

Over the next week, Sheila was visited by her community matron on two occasions.

At the first visit, the matron recorded a low temperature and a low heart rate and noted that Sheila had little appetite. No further observations were taken.

At the second visit Sheila appeared very low in mood and reported having hot sweats for a few days.

Sheila’s temperature, blood pressure and pulse were all within normal limits(Image: PA)

Again, her temperature was low and although the matron assessed and documented Sheila’s pressure sore risk and nutrition score, no other vital signs were recorded.

An electronic task was sent to the GP in regard to Sheila’s sweats but “no visit or telephone call appears to have been made”.

Three days later Sheila was admitted to Royal Derby Hospital with vomiting, abdominal pain, back pain and a loss of mobility.

She died a week later of urosepsis, a “severe” infection of the urinary tract.

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Dr Rick Meredith, medical director for Derbyshire Community Health Services NHS Foundation Trust, said: “In the past two years we have introduced a series of improvements to support our teams in caring for patients who may be at risk of serious infections, so that warning signs are spotted at the earliest possible stage.

“Our board meetings will always begin with a patient story, so that we can take learning from specific cases to help us make continuous improvements in care.

“Many changes in practice have been introduced in the past two years and we continue to place a high priority on supporting our staff to deliver the best possible care to patients.”

Creative Commons Disclosure

This article was originally published by Eddie Bisknell in Derbyshire LiveClick here to view the original article.

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Early warning signs missed as woman being cared for at home dies

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