FAI DETERMINATION SUMMARIES

Mr Harrison, who was referred to IRH with suspected sepsis by his doctor on 14 March, 2016, died the following day.

A Fatal Accident Inquiry found that an earlier administration of antibiotic to treat sepsis would have increased the chance of the treatment working, but that there was no evidence to conclude it would have prevented Mr Harrison’s death. 

A triage nurse scored him as a 9 on a National Early Warning Score (NEWS) assessment. The observations should have triggered a sepsis protocol where stickers would have been attached to the patient’s Emergency Department (ED) card, but this was not done. 

Mr Harrison was then seen by a junior doctor, who was part of  the medical receiving team. The junior doctor’s management plan was to obtain blood culture results, and a chest x-ray to determine if antibiotics should be administered, and to provide supplemental oxygen. The doctor did not access the nursing documents which mentioned sepsis or take any steps to seek to clarify the information provided by the GP practice. His clinical assessment did not point to a bacteriological chest infection, but to a lower respiratory tract infection or viral illness. The Inquiry found he should have discussed Mr Harrison’s case with a more senior doctor and should have highlighted that Mr Harrison was a patient who should have urgent review. The Inquiry accepted that, had that happened, the pragmatic course would have been for the immediate administration of sepsis antibiotics.

Later that night a second doctor found a more complicated picture and thought the most likely diagnosis was viral pneumonia and musculo-skeletal pain, which she attributed to coughing; but she also considered lung cancer.

In the early hours of the morning Mr Harrison’s condition had deteriorated and he was transferred to the High Dependency Unit. The Inquiry recorded that there was no criticism of the treatment of  Mr Harrison following his transfer to HDU, but by that time the opportunity for the early administration of antibiotics to counter sepsis had long since passed. His condition continued to deteriorate following his transfer to the Intensive Therapy Unit where at 17.25 he went into cardiac arrest and could not be resuscitated.

The FAI Determination states: “The failure to escalate the review of Mr Harrison to a more senior doctor and to follow protocols prejudiced the care provided to him. He did not receive the standard of care which should have been expected, even if the early administration of sepsis antibiotics may not have resulted in a different outcome.”

The Inquiry identified other shortcomings in Mr Harrison’s care, including:  

• The GP referral was not reviewed by the acute medical receiving team.  
• The Sepsis protocol was not implemented and Sepsis stickers were not affixed to the ED card.  
• Handover arrangements failed to result in early review of Mr Harrison and a decision on the prescription of antibiotics.
• Note keeping was not as accurate as it should have been.
  

The Sheriff Principal also found that the investigation into the death conducted by NHSGGC was inadequate in failing to identify key players and take statements. This resulted in factual inaccuracies and a failure to establish critical facts.

NHSGGC have since taken steps to remedy some of the identified issues, including improving both the induction of medical staff and training around the escalation of assessment of a deteriorating patient.

The Sheriff Principal wrote: “It is important to reassure the public that the Inquiry recognises the significant actions which have already been taken to improve the systems and care provided at IRH to avoid a recurrence of the system failures which have been identified in this case.”

The Determination has made five recommendations to NHSGGC:

• Steps should be taken to highlight to junior medical and nursing staff the need to escalate the assessment of patients who have a NEWS in excess of 7 in terms of the NEWS checklist.
• Consideration should be given to revising the guidance on significant adverse events to further emphasise the importance of establishing the facts of what happened, resolving any conflicts of evidence.
• Steps should be taken to remind staff who will be responsible for medically expected patients that they should consider what is said in the GP referral.
• Nursing and medical staff should be reminded of the need to sign or initial notes to identify the author and to record the time the patient was seen.
• Medical staff should be reminded of the manner in which drugs for immediate administration should be recorded on the once only prescription form and instructions issued to that effect.
  

The Sheriff Principal offered his sincere condolences to Mrs Harrison and the family and friends of Mr Harrison. 

Read the Determination.