Prevention of Future Deaths report secured after death of grandfather due to hospital’s failure to diagnose infection.

John was taken to Royal Stoke University Hospital after sustaining a cut on his foot that had become infected. Sepsis was initially suspected, he was placed on the ‘Sepsis 6’ pathway, and he was prescribed broad-spectrum antibiotics. The medical team concluded that John was delirious and that this was likely due to an infection.

The medical team initially considered a diagnosis of necrotising fasciitis (a very serious and fast acting tissue infection) but felt that to be unlikely as his LRINEC score was one. The LRINEC score is a tool used to support the early diagnosis of necrotising fasciitis. Its aim is to help distinguish necrotising fasciitis from other severe but non-necrotising soft tissue infections, such as cellulitis or an abscess.

It was later revealed that his LRINEC score had been calculated incorrectly and should have been five instead. Because of this, necrotising fasciitis was excluded, and the treating team were falsely reassured about his condition. An MRI scan was requested, however, because the medical team no longer suspected necrotising fasciitis this was not treated as urgent and was not prioritised for the same day.

The following day John was transferred to the Acute Medical Unit. Whilst there, he was not reviewed by the orthopaedic team, and he did not receive three doses of antibiotics, despite these being prescribed.

It was not until two days later that the MRI was chased up as it had not been undertaken. By this point, John was too ill to undergo the MRI and medical staff noted that he might be suffering from acute severe invasive tissue infection. He was taken to the operating theatre for a below the knee amputation, to remove the infected limb.

Unfortunately, despite the amputation surgery, John continued to deteriorate when transferred to the Intensive Treatment Unit. Sadly he then passed away overnight.

After John’s death, Jane received notification that a coroner’s inquest would be held into the circumstances of the death. Jane approached our experienced inquest representation solicitors to support her with navigating this process.

In preparation of the inquest, we liaised with the coroner’s court on the family’s behalf to ensure John’s case was fully investigated. We gathered and analysed John’s medical records, witness statements from relevant witnesses and the Hospital’s Patient Safety Incident Investigation Report which detailed the findings of the internal investigation that took place.

We made submissions to the court about the arrangements for the final inquest hearing, including which documents should form part of the inquest evidence and which witness ought to be called to give oral evidence in court to assist the coroner’s inquiry.

The inquest hearing uncovered that, had the appropriate scoring being assigned initially and there had not been any delays in performing the MRI, the medical team would have realised sooner that John was suffering from severe invasive tissue infection and would have operated sooner to remove the source of infection. It was further confirmed that he would have had a higher chance of survival if John had undergone surgery sooner.

Through questioning of witnesses at the inquest on behalf of the family, it became clear that the hospital had an inadequate medication dispensing system in place. When signing medication out for patients, no signature was required when the medication is not available to administer. This meant that there was no audit trail if a patient is not given medication as prescribed and so this omission wasn’t recognised or appreciated fully at the time.

Given the evidence that was heard during the course of the inquest, submissions were made successfully on behalf of the family that the coroner ought to prepare a Prevention of Future Deaths Report (PFD Report) to address the concerning practice at the hospital, which was felt to pose a threat to the lives of other patients if left unresolved.

The coroner agreed and prepared a PFD report which was sent to NHS England and University Hospitals of North Midlands NHS Trust, for them to respond to the coroner’s concerns.

The coroner’s report highlighted issues in respect of a nationwide lack of awareness regarding invasive soft tissue infections which creates a risk of further missed or delayed diagnoses. The coroner also highlighted her concerns about the hospital system for signing out medication and the fact that no signature is required when the medication is not available, which prevents an appropriate audit trail being kept.

University Hospitals of North Midlands NHS Trust have since issued a response, setting out how they have addressed the coroner’s concerns, including:

• confirming their support of any national work to raise awareness of severe invasive soft tissue infections;
• implementing a significant training and learning programme within the Trust to raise further awareness of the condition and its management;
• scheduled implementation of an electronic medicines administration system at the Trust, which will provide a robust and transparent record of all medication activity, including when a dose is omitted, the reason for omission and the identity of the person making that decision;
• pending the roll out of the integrated electronic system they have developed a Patient Safety Learning Alert requiring staff to document reasons for drug omissions.

At the time of writing a response is awaited from NHS England.

We are supporting John’s family with their claim against the hospital for the failures leading to his untimely death. The family’s primary motivation is to hold the hospital to account and to raise awareness about severe soft tissue infection so that no other person finds themselves in the same situation.

Jane, John’s wife, said:

“We are thankful to the coroner for her careful consideration of the inquest. Whilst we are grateful that a Prevention of Future Deaths Report has been issued and further awareness is being raised of this dangerous condition, it is nonetheless heartbreaking to know that John’s treatment was flawed in so many ways. Life is very quiet without him and we all miss him terribly”.

Miryam Vermaat, lawyer representing the family, said:

“There were several missed opportunities during John’s care, all of which delayed vital treatment being provided. We welcome the coroner’s decision to write a Prevention of Future Deaths Report and we hope that the actions taken as a result will ensure this doesn’t happen again. “

The family were represented in the inquest by Miryam Vermaat at RWK Goodman, assisted by barrister, Lauren Karmel of St John’s Chambers.

*Please note that names have been altered in order to preserve the family’s anonymity.