A father from Birmingham went to the hospital with pain in his arm, but died 36 hours later after the doctors did not spot a "carnivore" condition in time.
Dennis Pearce was admitted to Birmingham Heartlands Hospital with an abscess in his right armpit. But the CT scan projects to diagnose the source of the infection were only planned at 5:00 am the day after admission to the previous lunch.
The father of two children, Yardley, was found too sick for surgeons to remove the infected tissue after cardiac arrest.
His health continued to deteriorate and his family, including his wife Jacqueline, decided to withdraw his life-saving treatment on the advice of doctors. They had been married for 50 years.
An internal hospital investigation report revealed that a "lack of recognition" of sepsis by doctors meant a "missed opportunity" to diagnose that the 73-year-old patient had necrotizing fasciitis and remove the infected tissue.
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His daughter Karen said, "He was a wonderful husband and father. He was the base of our family. It is so difficult to put into words the events that have unfolded.
"This is the hardest decision for all of us. It was a complete shock and absolutely devastating to receive the report by mail, which pointed out many failures in dad's care, which could have caused his death. "
The internal report revealed that sepsis was only diagnosed nearly nine hours after Dennis' admission to the hospital and that it was not expected to scan the source of the infection. Infection before 14 hours after admission, time when it was too late.
Following Dennis' death, his family commissioned an expert medical negligence lawyer from Irwin Mitchell to investigate his care at the University Hospitals of the Birmingham NHS Foundation Trust, which runs the Heartlands Hospital.
The family, including his 52-year-old son Wayne, has now joined his legal team to mark World Sepsis Day on September 13 by urging health professionals to be more aware of the signs of the disease.
What happened to Dennis
Karen had taken her father to A & E shortly after 1:30 pm on October 4, 2018, while complaining of right arm pain and nausea. His right elbow was inflamed, he had a limited movement in the arm and an abscess in the right armpit. He had not eaten for three days either. Karen had to leave him to go back to work.
Jacqueline, a former care assistant, said that she had telephoned the hospital several times a day to watch over her husband, a retired production worker, and that she thought that she was not sure what to do. it was subjected to routine tests.
Irwin Mitchell told BirminghamLive that Dennis had been examined by a generalist working in the emergency department, who had then referred him to a medical specialist in surgery. After an examination at 5 pm, he concluded that Dennis had no abscesses and forwarded his care to the trauma and orthopedic team, who stated that no contribution was required from the team.
Following further examinations and X-rays, at 10:25 pm, a registrar diagnosed Dennis with sepsis, with the possible source of infection being his right armpit. Dennis's condition continued to deteriorate. Plans for a scanner to locate the source of infection were developed at 5 am the next morning. However, on October 5, he suffered a cardiac arrest around 6:30 am before undergoing the examination.
Dennis's family was called and invited to the hospital, being on the verge of death. He died at 12:40 the next day.
The conclusions of the report
The report concluded that the "root cause" of Dennis' death was that he should have been examined earlier by a senior staff member to determine which team had to take care of him.
The report also found:
· It was "necessary to surgically remove earlier" the infected tissue, but this was forgotten because of the delay in the diagnosis of sepsis
· The junior and middle doctors have shown a "lack of recognition" of the sepsis or the source of the infection.
· The Trust's policy of transferring Dennis's care to an older physician was "not followed"
· There was a "lack of communication" between the medical teams to know who should take care of Dennis.
· "No good practice has been identified beyond the expectations of the trust".
The Trust also faced a "significant delay" in completing its own investigation because the staff involved in Dennis' care had not included "basic information" such as their name, position, location and the moment they looked at Dennis in his notes.
Sepsis is the life-threatening body reaction to an infection. This happens when the immune system overreacts and starts to damage the body's own tissues and organs. You can not catch sepsis from another person. Learn more here
Dr. Ron Daniels, Managing Director of the UK Sepsis Trust, said: "Every year in the UK, 250,000 people are affected by sepsis, of which 52,000 die from this disease. However, if the diagnosis is diagnosed quickly, it is easy to cure sepsis and we believe that a faster diagnosis and treatment across the UK would save at least 14,000 lives a year.
"Every hour that passes before the administration of the right antibiotics increases the risk of death. Increased awareness could save thousands of lives and together we can change the way sepsis is treated in the UK. "
Jennifer Shipley, a medical negligence lawyer at Irwin Mitchell representing the family, said, "Thanks to our work, we have seen many times the terrible impact that sepsis can have on people who are not not treated as quickly as possible.
"Naturally, Jacqueline and the rest of the family remain devastated and extremely troubled by the worrying problems with the care Dennis has been given and identified by the Trust. We are now working with the Trust to address the concerns of the family.
"Early detection and treatment is the key to overcoming sepsis. We urge all health professionals to be more aware of the symptoms of the disease at all times. "
Karen added, "It may have been almost a year since he passed away, but the pain and pain we continue to feel is still as raw as it is today. What makes it harder to accept is that we never really said goodbye to dad because he was so bad.
"All we can hope for now is that by learning from it, we are learning and more people are realizing how dangerous sepsis can be.
"It's so important that the symptoms are detected quickly so that those who suffer can receive the best care available as soon as possible."
What must be done to prevent this from happening again
The report contained eight recommendations, including:
· A registrar or higher physician must evaluate a patient transferred to a specific medical team by A & E.
· The Fiducie's "expectations" of when patient care should be intensified to be included in the induction of young physicians
· A specialized group will be set up to examine and develop ways to treat patients who may be diagnosed with necrotizing fasciitis.
Attorney Jennifer Shipley added, "We are delighted that the Trust has made a number of recommendations as a result of its investigation, as the family now wants lessons to be learned.
"It is now vital that these recommendations are implemented and adhered to at all times by staff to improve patient care."
What the hospital says
A spokesperson for the Birmingham NHS Foundation, University Hospitals, said, "The Trust extends its condolences to Mr. Pearce's family. UHB takes its responsibilities to all of its patients very seriously and is always ready to learn from events to improve the care provided.
"In this case, a survey was conducted and improvements in practice were identified. The rapid treatment of sepsis is a priority that is the subject of a number of initiatives monitored, measured and communicated regularly.
"We will continue to liaise with Mr. Pearce's family, who, according to our information, has recently been instructing lawyers."