The man died at Sandwell General Hospital after he was initially discharged before blood cultures tests were ready.
In late February 2022, an elderly man died after a failure to recall him to Sandwell General Hospital, part of the Sandwell and West Birmingham Hospitals NHS Trust, when a staph infection was diagnosed by a laboratory.
He was brought to Sandwell General Hospital via ambulance with a fever, vomiting, symptoms of a urinary tract infection (UTI), as well as an acute kidney injury and treated with antibiotics. The next morning, when he was reviewed by a consultant, his blood tests showed an improvement in infection markers, and he was discharged home with a course of oral antibiotics.
The results of blood cultures tests were not ready before he was discharged.
On 1 March, a doctor from the microbiology department noted that the blood culture taken from the patient had grown methicillin-sensitive staphylococcus (MSSA) bacteria – more commonly known as a staph infection. This requires different, specific antibiotics. Although the results were reported to the treating team, they disregarded these findings, instead concluding that the results likely represented a contamination of the sample taken.
Although the patient continued to feel ill, he was not called for another blood test, and his GP was not made aware either of the results from the hospital or which antibiotics had been prescribed.
Failure to recall
An ambulance was called to the patient’s home on 18 March, after the patient was found collapsed on the bedroom floor, confused and complaining of abdominal pain.
Paramedics diagnosed the patient with probable urosepsis with a fever. He was taken to hospital for further examination, and he remained unwell in the emergency department. He was diagnosed with catheter-associated urosepsis, an acute kidney injury and a lower respiratory tract infection.
Later that month, the patient’s condition had deteriorated significantly. He was found to be suffering from endocarditis – an infection of the inner lining of the heart associated with an uncontrolled and invasive staph infection.
A CT scan revealed that the patient had had ischemic strokes, which occur due to disrupted blood flow to the brain. He had also developed multiple organ failure and remained unconscious. An MRI brain scan confirmed that he had an extensive haematoma, and the neurosurgical team at the hospital advised that no surgical intervention at this stage would be of benefit.
Sandwell and West Birmingham Hospitals NHS Trust admitted a failure to recall the patient for treatment following his blood test results in March that indicated MSSA bacteria. It also admitted that if the results had been properly acted upon, the patient would have been treated with the appropriate antibiotic treatment, and that it was likely that he would not have deteriorated and suffered sepsis and brain injury as a result of the staph infection, and that his death would have been avoided.
A serious incident investigation also took place to address the failings in the patient’s care, recommending changes to prevent similar incidents from occurring again.
