The death of a 26-year-old woman who lost her life to sepsis was avoidable, an investigation has found.
Anna Hemmings she was admitted to the hospital in October 2015 suffering from a chest infection, a urinary tract infection (UTI) and sepsis.
A review by the Parliamentary and Health Service Ombudsman, (PHSO, found that staff at Doncaster and Bassetlaw Hospitals NHS Foundation Trust did not diagnose and treat the life-threatening condition quickly enough, and she died as a result.
The findings of the investigation have been published on World Sepsis Day today.
Even though Anna’s symptoms and tests clearly showed that the UTI was the most likely cause of the sepsis, hospital staff did not sufficiently act on this and focussed on treating her chest infection.
The hospital also failed to monitor her condition and ensure that Anna, who had spina bifida, hydrocephalus and was partially sighted, was given enough fluids.
This meant she wasn’t given the correct antibiotic until 15 hours after she had been admitted but by then it was too late and she suffered a heart attack and died.
Rob Behrens, Parliamentary and Health Service Ombudsman, said lessons must be learned.
He said: “Doctors and nurses do an important job in caring for hundreds of thousands of people every day under enormous pressure.
”But as this case shows, it is essential that the NHS learns from mistakes and ensures that sepsis is promptly diagnosed and treated. This will ultimately save lives.
”This case also highlights the importance of people speaking up when things go wrong so that changes and improvements are made to NHS services.’
Anna’s mum, Katie Hemmings, brought the complaint about the Trust to the Ombudsman on behalf of her daughter’s extended family after the Trust’s own investigation failed to recognise several serious mistakes in her daughter’s treatment.
The Ombudsman found that the Trust’s local investigation did not acknowledge that if it had provided the right treatment then Miss Hemmings could have survived.
Dr Ron Daniels, Chief Executive of the UK Sepsis Trust, said Anna had been failed by the NHS.
He said: “Sepsis is a complex condition in which early recognition demands an alert healthcare system.
"We must never become accustomed to cases such as this tragic death of a young woman in which the system failed her. Healthcare organisations must learn from such events and take robust steps to ensure that mistakes are never repeated.”
Mr Sewa Singh, Medical Director at Doncaster and Bassetlaw Teaching Hospitals, said awareness of sepsis had improved since Anna's death.
“We accept that there were aspects of care which the Parliamentary and Health Service Ombudsman (PHSO) identified could have been improved.”
"When Anna was brought to Doncaster Royal Infirmary, the presence of septicaemia was recognised and she was commenced on intravenous antibiotics. When Anna’s condition did not improve, the antibiotics were changed but sadly Anna passed away from the effects of septicaemia.
“The early detection and treatment of sepsis is an NHS-wide priority and we continue to put in place better education, the promotion of sepsis awareness across the Trust and have improved guidance for all clinical staff.
“We are pleased to have been able to work closely with Anna's mother, Katie, who will join us as we mark World Sepsis Day.”