Sepsis VTE Collaborative Learning Session 3 Kevin Rooney

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

A story of missed opportunities

• 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.

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

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

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

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

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

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