Hereford sepsis death 'so easily avoided'

More must be done to ensure NHS staff are aware of the signs and symptoms of sepsis, an ombudsman says, following the "avoidable" death of a patient.

Stephen Durkin, 56, died in 2017 after the Wye Valley trust in Herefordshire failed to diagnose and treat the life-threatening condition quickly enough, an investigation found.

The ombudsman said within 48 hours his condition "deteriorated rapidly".

The trust said it had since "swiftly improved training and monitoring".

Sepsis, sometimes called septicaemia or blood poisoning, occurs when the body overreacts to an infection and starts to damage tissues and organs.

Mr Durkin died after suffering organ failure from sepsis, the Parliamentary and Health Service Ombudsman (PHSO) said.

Its investigation found the trust did not diagnose and treat sepsis quickly enough.

The factory worker from Hereford was an "otherwise healthy" 56-year-old, when he attended A&E at The County Hospital in the city in July 2017 with chest pain.

Hospital staff suspected Mr Durkin had a major blood vessel blockage and admitted him to a ward overnight.

The next morning his overall condition had worsened, but staff "did not monitor him more closely, as national guidance advises", and he deteriorated during the day, the PHSO said.

The next day he was admitted to intensive care and treated for sepsis, but died later that evening.

The ombudsman said the critical care team attended to Mr Durkin 10 hours "too late".

His wife Michelle, who complained to the ombudsman, said she hoped by "highlighting the mismanagement of Stephen's treatment and care" it would prevent anyone else from experiencing "the same tragic journey myself and family have had to take".

Ombudsman Rob Behrens said the death "could so easily" have been avoided.

"His case shows why early detection of sepsis, as set out in national guidelines, is crucial.

"It is vital that NHS trusts ensure their staff are sepsis-aware to reduce the number of avoidable deaths."

The PHSO said the Wye Valley trust had provided "extra training to its staff in sepsis management and advanced communication skills".

The ombudsman added the trust "explained that since doing so, it has seen a 'considerable reduction' in sepsis-related deaths".

It also said the trust had agreed to pay Mrs Durkin £17,000 "in recognition of the injustice she suffered as a result of its failings".

The organisation said it apologised "unreservedly to Stephen's wife and family for the delay in his diagnosis and treatment for sepsis".

Its chief medical officer, David Mowbray, said: "The trust swiftly improved training and monitoring to prevent deaths from sepsis wherever possible, and we continue to monitor and evaluate any sepsis-related deaths to ensure patients receive the highest standard of care."

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