A 45-year-old disabled father of two died from sepsis after waiting 34 hours for vital antibiotics at a hospital in the Midlands, an official investigation has found.
Systemic Failures in Treatment
The man, who lived in supported accommodation in Ollerton, Nottinghamshire, had Alexander disease, a rare and incurable disorder affecting his nervous system. The condition caused significant respiratory and mobility problems, requiring full-time care. Due to his illness, he used a permanent catheter and was vulnerable to frequent urinary tract infections.
In November 2022, he developed an infection that was resistant to oral antibiotics. His GP subsequently referred him to Bassetlaw Hospital, part of the Doncaster and Bassetlaw Teaching Hospitals NHS Foundation Trust, for urgent intravenous (IV) antibiotic treatment.
Delays and Dosage Errors
An investigation by the Parliamentary and Health Service Ombudsman (PHSO) revealed a catastrophic series of delays and errors. Despite advice from paramedics and care home staff to administer IV antibiotics promptly, hospital doctors did not follow this guidance.
After consulting a microbiologist, medics decided to use an oral antibiotic instead, only to find it was unavailable. The PHSO stated that doctors should have sought further advice, which would likely have led to the IV drugs being given much sooner.
The patient finally received his first IV dose over 34 hours after arriving at the hospital, and it was administered at only half the required strength. A second, delayed dose was given after he had already developed sepsis. He passed away a week later.
Communication Breakdown and Accountability
The man's disabilities made it difficult for him to communicate his concerns to staff. His 70-year-old mother repeatedly voiced her worries, informing doctors that the oral antibiotic would not work based on a microbiologist's report provided by the GP.
"They just totally dismissed me," she said. "Their attitude was they were the doctors and I was just his mum." She was never told her son had not received any antibiotics during the long wait.
The PHSO concluded his death was preventable. In response, the Trust has agreed to write a formal apology to his mother, provide financial compensation, and implement an action plan to prevent future tragedies.
Karen Jessop, chief nurse at the Trust, said: "We are truly sorry for what happened in this case and for the loss experienced by the patient's family." She added that immediate actions were taken to strengthen how antibiotics are prescribed and administered.
Rebecca Hilsenrath, chief executive of the PHSO, warned that complaints about sepsis have more than doubled in five years, with the same failings recurring. "Losing a life through sepsis should not be an inevitability," she stated.
