Recognition Of Sepsis In A Deteriorating Patient

Health and Disability Commissioner Anthony Hill today released a report finding a doctor and a health centre in breach of the Code of Health and Disability Services Consumers’ Rights for failing to recognise an elderly man was deteriorating with an infection.

The man was in his eighties and had a number of health issues. He was receiving care at a small rural hospital operated by the health centre. While at the hospital, the man’s vital signs deteriorated over two days, and other tests, including an X-ray, revealed flags for infection. However, the doctor did not recognise the infection or change the man’s treatment, believing the man to have heart failure. The man continued to deteriorate and died from blood poisoning caused by a urinary tract infection.

Anthony Hill considered that the doctor should have recognised that the man had an infection and given him antibiotics. The doctor should have synthesised his observations with all the information available to him, rather than interpreting results in isolation.

"[The doctor] failed to identify that [the man] had developed sepsis despite a number of convincing factors indicating that he had, with the consequence that [the doctor] did not provide antibiotics to [the man] in accordance with accepted practice," Mr Hill said.

Mr Hill was critical that the health centre did not have a sepsis pathway or Early Warning Score system in place to assist staff with responding to patient deterioration. Although the health centre has since put appropriate policies in place, Mr Hill recommended that the health centre review and audit their effectiveness. He also recommended that the doctor undertake further education, and that both the doctor and the health centre apologise to the man’s family.

The full report for case 17HDC01683 is available on the HDC website

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