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The death of a 45-year-old disabled man could have been prevented if he waited 34 hours for antibiotics in hospital, an inquest has concluded.
The father-of-two died from sepsis after being referred to Bassetlaw Hospital in Nottinghamshire for intravenous antibiotics to treat a urinary infection. Parliamentary and Health Services Ombudsman (PHSO).
Living in supported housing in Allerton, Nottinghamshire, the man suffered from Alexander’s disease, a rare and incurable neurological disorder that causes growth delays, respiratory and mobility problems and requires 24-hour care.
The PHSO said his condition means he has an indwelling catheter and is vulnerable to urinary tract infections.
He developed a disease that was resistant to oral antibiotics in November 2022 and was referred to Bassetlaw Hospital by his GP.
The PHSO investigation found that he was given the correct IV medication more than a day after arriving at the hospital, and that half the dose should have been given.
By the time the second dose was given, which was also delayed, the man had become septic and died a week later.
The report found that due to his disability he had difficulty communicating with staff and lacked treatment.
His mother also raised concerns about his treatment to staff at the time but was never told that he did not receive antibiotics.
The ombudsman also found that paramedics and care home staff told the hospital they needed IV antibiotics, but doctors did not comply with the request and after consultation with a microbiologist decided to try oral medications, but discovered these were unavailable.
The investigation found that doctors should have requested further advice which likely would have led to IV antibiotics being administered more quickly.
Doncaster and Bassetlaw Teaching Hospitals NHS Foundation Trust, following recommendations from the PHSO, agreed to write to the man’s mother to acknowledge the failings and apologise, offer her financial support and set out an action plan to prevent a similar incident happening again.
The man’s 70-year-old mother said: “I knew my son better than anyone and I was trying to help by telling the doctors that oral antibiotics wouldn’t work and the GP had a report from a microbiologist saying he would have no effect on that drug. But they completely dismissed me.
“His attitude was that he was the doctor and I was just his mom.”
He added, “It was heartbreaking to finally learn the truth. I got the impression that she was given at least some antibiotics, even if they weren’t the right ones.
“But it was very difficult to find out that he was in the hospital for so long without any treatment.
“It won’t bring my son back but it has given me closure and now no one else will have to go through the same thing because the trust has been held accountable.”
Rebecca Hilsenrath, chief executive of PHSO, said: “Losing life due to sepsis should not be inevitable. But we are seeing the same failings repeated again and again, and complaints about sepsis have more than doubled in the last five years.
“We also see poor communication between patients and clinicians and we are focusing our efforts on helping to improve this across the NHS.”
Karen Jessop, chief nurse at Doncaster and Bassetlaw Teaching Hospitals, said: “We are really sorry for what happened in this case and the loss caused to the patient’s family.
“We reviewed the information and care provided at the time through our patient safety panel. Immediate actions were implemented to strengthen the way antibiotics were prescribed, escalated and given.”