HDC case - sepsis

The coroner (Coroner Ho) has released final findings in relation to the 2018 death of a woman who died of sepsis and directed a copy be made available to the Royal New Zealand College of General Practitioners.

There has been recent media attention to this case and it’s relevant to general practitioners.

The case
On 22 November 2018, a 96-year-old woman (Mrs B) died of sepsis as a complication of a laceration to her leg that had occurred a month before and had been treated at an emergency department (ED).

Background
Although Mrs B was described as living independently in her own home, she had care workers visiting three times a day, along with regular visits from her daughter. When she suffered the laceration to her leg, the ED arranged for regular dressings by the district nursing service and five different nurses saw her over a period of a month. Each nurse documented their impression of the progress of the wound healing.

On the 9 November, the district nurses advised Mrs B that she should have the wound checked by her doctor, but she was reluctant to because “she did not want to spend the money on a GP visit.” The district nurse did however discuss the case with a practice nurse. This is documented, particularly noting that Mrs B had “a malodorous wound” but she “was adamant that she did not want to go into rest home care.”

On a second occasion (12 November) there was a cryptic entry in the practice notes stating “IBx:Swab,” probably written by a receptionist and relating to a phone call where the district nurse was alerting the practice to the fact that she had taken a wound swab on 12 November, and that the result would appear in the doctor’s inbox.

Following up on the 9 November note, her general practitioner (Dr G) visited her on the 13 November (almost certainly before the swab result would have been reported) with the specific purpose of carrying out a cognitive assessment to determine her mental capacity and whether she needed permanent rest home care. The issue of the leg wound was not raised, and her doctor did not look at or examine the wound. In fact, as the Dr was leaving the patient’s home, she encountered the district nurse and a brief discussion occurred, obviously with the Dr mistaking the district nurses questioning about the patient’s leg as a question about her mental capacity.

When later questioned, Dr G stated that she considered that district nurses were the experts in wound care and she would not have taken down the dressing to look at the wound.

The district nurses continued to manage the wound and although they reported on its status, there was a retrospective comment that the various reviews gave a confusing picture as to whether the wound was infected or not. On the 22 November, Mrs B was found by a caregiver, pale and confused. An ambulance was called, and she was admitted to hospital but died a few hours later.

This was a sad outcome for a frail elderly patient, but one which many of us would have been familiar with. So why did the coroner become involved, albeit reporting some four years later?

Coroner’s findings
The coroner’s first concern focuses on the swab that was taken on 12 November, and who was responsible for acting on it. This is a critical point as the swab appears to have been sent to the laboratory under the name of the patient’s doctor (Dr G). Although there was a cryptic message left about the existence of the swab, it would have meant that the Dr would have had to have read (and understood) the message.

The district nurse did not have any easy or efficient access to the swab result. Although she could have logged into a hospital electronic system, this was onerous, and a paper result would not have arrived a week or more. What is more, a simple swab result identifying “a heavy growth of streptococcus and heavy growth of staphylococcus aureus” would not have meant very much without clinical context.

The coroner’s view was that the responsibility for the swab and passing on the information in a relevant manner was that of the district nurse. However, once that information was passed on, then it became a joint responsibility.

This then leads on to the nub of this case: how well did the district nurse communicate with the GP and vice versa? Here the coroner recommends that ideally case records belonging to the district nurse service should be shared and a “universal shared record” should be developed – something we cannot disagree with, but plainly this is a “vision” that has been around for many years and likely to be there in visionary form for even longer.

Comment
The reality is that many of these problems could have been resolved by developing a clear communication between the district nurse and the general practitioner, as well as a clear understanding as to who had overall responsibility for the patient’s welfare.

The relationship between a general practitioner and a hospital-based health provider is often fraught. In this case the district nurse was obviously aware of the potential cost barrier for the patient, and this may have delayed referral.  A possible solution could be that when there is a combined primary and secondary care input, the cost barrier should be removed with extra funding.

The other very important point is that the clinician who orders a test is responsible for ensuring the test is followed up. This principle is to ensure the safe care of patients across the system.

Communication with the district nurse
There need to be clear decisions as to who is responsible for a patient’s management and a message like the one below would have been ideal:

“I am concerned that Mrs B’s leg is infected and I have taken a swab. Could you assess and treat as you feel fit?”

This should have been a conversation between the district nurse and the doctor without the use of intermediaries. Such a communication would cement a collegial relationship and easily establish who was in overall charge. Alternatively, the conversation could be via a reliable messaging system to the doctor who could also message back. This could possibly have been undertaken via existing portals.

The failure of our systems to allow efficient communication between clinicians is a flaw that can lead to patient harm and put clinicians at risk.

Communications with hospital services
If this patient had been given antibiotics in a timely manner, but still collapsed and died in hospital, it might have generated another simple communication from the hospital clinician:

“Hello Dr G, your patient has just died of sepsis, but I see that you were managing that. Are you happy to write a death certificate?”

From Dr G:

“Yes, we did the best we could for her. I will write the certificate and have a chat to the family”.

So simple and it uses existing technology.

And it might have saved the coroner a lot of work.

And it might have taken a great weight off the minds of the family and the health professions involved.