Failure to refer to district nursing before woman’s sepsis death
Posted 30 May 2024 - 12:52
District nurse referral did not happen after key information was missed from hospital discharge summary and GP surgery failed to act when patient reported pain
A coroner has raised concerns about the death of a patient from sepsis after a hospital and GP surgery failed to refer her to the district nursing team.
Linda Heath, 76, died from sepsis in March 2022 at Hull Royal Infirmary, having been discharged from the same hospital with a grade 2 sacral pressure sore on 11 February. With no community nursing care in place, the sore became infected and she was re-admitted to hospital on 5 March. Despite surgery, her condition and complications worsened and she died of sepsis on 31 March.
Repeated failure to refer to the district nursing team
East Riding and Hull assistant coroner Sally Robinson this month sent a prevention of future deaths report to NHS England, the Nursing and Midwifery Council (NMC), the Care Quality Commission, as well as Hull University Teaching Hospitals NHS Trust and St Andrews Surgery in Hull, in order to highlight failures in Ms Heath’s care.
The report said although the nursing summary in the patient’s notes stated care would be transferred from the hospital to a district nursing team, to include dressing selection and equipment required at home, this was not added to the immediate discharge summary. Therefore, a referral was not made by the hospital.
‘No trigger appears to exist whereby GPs conduct follow-up enquiries or visits to patients who have recently been discharged from hospital and who are complaining of a condition which may worsen and failing to attend routine appointments due to a worsening of their condition’
Sally Robinson, East Riding and Hull assistant coroner
Three days after leaving hospital, Ms Heath contacted her GP about her sore and was prescribed Zenoderm cream over the phone. A few days later, she missed a routine bloods appointment at her GP surgery because she was in ‘too much pain’ from the sore, but again a referral to the district nursing team was not made.
Finally, the GP made a home visit on 4 March and immediately had Ms Heath transferred to hospital.
‘Healthcare professionals’ management issues’
The inquest into the death of Linda Heath, held in April, reached a narrative verdict.
East Riding and Hull assistant coroner Sally Robinson stated a series of ‘management issues by healthcare professionals’, including the failure to refer her to a district nursing team, led to the worsening of Ms Heath’s condition.
Lack of GP follow-up must be addressed
The coroner raised concerns that action should be taken to prevent future deaths. She added in her report: ‘Despite the presence of a difficult sacral sore, which would have benefitted from district nursing care, no referral was made post-discharge by the GP surgery.
‘No trigger appears to exist whereby GPs conduct follow-up enquiries or visits to patients who have recently been discharged from hospital and who are complaining of a condition which may worsen and failing to attend routine appointments due to a worsening of their condition.
‘In my opinion, action should be taken to prevent future deaths and I believe your organisation has the power to take such action.’
A spokesperson for St Andrews Surgery said: ‘In light of the report, we have thoroughly reviewed and enhanced our procedures and processes, which now incorporate more robust procedures and training.'
A Hull University Teaching Hospitals NHS Trust spokesperson said the organisation would respond to the coroner in due course.
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