An investigation has concluded that the death of a 45-year-old disabled man, who waited 34 hours for antibiotics in hospital, was preventable.
The father-of-two died from sepsis after being referred to Bassetlaw Hospital in Nottinghamshire for intravenous antibiotics to treat a urine infection, according to the Parliamentary and Health Service Ombudsman (PHSO).
Living in supported accommodation in Ollerton, Nottinghamshire, the man suffered from Alexander disease, a rare and incurable neurological disorder that caused developmental delays, respiratory and mobility issues, and necessitated 24-hour care.
The PHSO said his condition meant he had a permanent catheter and was susceptible to urinary tract infections.
He contracted one in November 2022 that was resistant to oral antibiotics and was referred by his GP to Bassetlaw Hospital.
The PHSO investigation found he was given the correct IV medication more than a day after he arrived at hospital, and at half the dosage it should have been.
By the time a second dose was given, which was also delayed, the man had become septic and he died a week later.
The report found his disabilities meant he had difficulties communicating with staff and raising the lack of treatment.
His mother also raised concerns about his treatment with staff at the time but she was never told he had not received the antibiotics.
The ombudsman also found that paramedics and care home staff told the hospital he needed IV antibiotics but medics did not follow the request and decided to try oral drugs after consultation with a microbiologist, only to find it was unavailable.
The investigation found doctors should have requested further advice which probably would have led to IV antibiotics being administered more quickly.
Doncaster and Bassetlaw Teaching Hospital NHS Foundation Trust agreed to write to the man’s mother to acknowledge the failings and apologise, pay her a financial remedy and prepare an action plan to prevent a similar incident happening again, after recommendations from the PHSO.
The man’s mother, 70, said: “I knew my son better than anyone and I was trying to help the doctors by telling them the oral antibiotic wouldn’t work and that the GP had a microbiologist’s report that said he wouldn’t respond to that drug. But they just totally dismissed me.
“Their attitude was they were the doctors and I was just his mum.”
She added: “It was heartbreaking to finally understand the truth. I was given the impression he had at least been given some antibiotics, even if they weren’t the right ones.
“But to find out he was in hospital for all that time with no treatment was very hard.
“It won’t bring my son back but it has given me closure and no one else should have to go through the same thing now that the trust has been held to account.”
Rebecca Hilsenrath, PHSO chief executive, said: “Losing a life through sepsis should not be an inevitability. But we are seeing the same failings repeated time and time again, and complaints about sepsis have more than doubled over the past five years.
“We also see poor communication between patients and clinicians and we are focusing our efforts to help improve this throughout the NHS.”
Karen Jessop, chief nurse at Doncaster and Bassetlaw Teaching Hospitals, said: “We are truly sorry for what happened in this case and for the loss experienced by 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 how antibiotics were prescribed, escalated and given.”
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