1. Sepsis VTE Collaborative
Learning Session 3
Kevin Rooney, National Clinical Lead for Sepsis and Rhiann Oliver

6. A story of missed opportunities

7. 60 year old male Admitted with a fall Died 22 hours later
6 missed opportunities
NHS Greater Glasgow & Clyde conducted a SAER after 2 separate people report concerns. We are very grateful to the Board for sharing their learning.
A 60 year old man is admitted to E.D. after a fall at home. He died in the admissions unit about 22 hours after admission. During his care there were 6 missed opportunities to treat the sepsis that led to his death.

8. Opportunity 1 – on admission
EWS 4 – no sepsis screen
No IV cannula
Prescribed antibiotics IV/oral
Antibiotics given orally after 3 hours

9. Opportunity 2 – 2 hrs post admission
Seen on assessment unit by junior doctor
Plan for urgent antibiotics, oxygen and urine sample
No lactate sample
Oxygen starts 4.5 hrs after admission
IV Antibiotics 6 hours after admission
No medical reassessment or senior review

10. Opportunity 3 – overnight
EWS 7 – no increased monitoring or escalation
9 hours post admission, noted as sweating ++ Temp 35.8° - no EWS scoring done
13 hours post admission – EWS 6. Escalated to junior doctor. Has not passed urine since admission

11. Opportunity 4 – morning medical review
Ordered fluid challenge, no lactate, no documentation of findings

12. Opportunity 5 – ward round
Nurse documents concern EWS 5
1 hour later EWS 7 – SCN alerted and is concerned
Consultant ward round continuing in bed order – previous system to prioritise sick patients abandoned

13. Opportunity 6 – seen by Consultant
Diagnosis of sepsis & plan to treat
Handed to junior doctor who is also asked to continue with ward round
Junior doctor hands on plan to colleague
Ward round leaves to see boarders
No beds in HDU
Seen by HDU doctor by chance 1 hour later who initiated consultant plan. Lactate 5.6
Suffers cardiac arrest & dies prior to HDU transfer