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Sepsis, Systems and Serious Flaws9th February 2016 Clinical Negligence
A death, under any circumstances, is a terrible occurrence. In addition to the life lost, it can leave relatives looking for answers about how and why it happened and whether more could have been done to save their loved one. When the deceased is a child, there is also the element of a life painfully unfulfilled.
If that death has followed examples of inadequate healthcare, involving mistakes or missed opportunities, heartache is compounded by natural frustration.
These are emotions familiar to myself and my colleagues in JMW's Clinical Negligence department from many, many cases. They are also evident from a new and shocking case.
A report has just been published by NHS England into the death of a one-year-old boy, William Mead, in December 2014. The publication followed a detailed investigation into the circumstances preceding and following his death.
It found that although the cause of death was put down to natural causes, an inquest rightly concluded that he had instead died from treatable blood poisoning, known as sepsis, caused by a chest infection. Furthermore, the inquiry uncovered serious flaws in his treatment and the performance of the much-criticised NHS 111 helpline.
They included the fact that William's GP had failed to recognise the severity of his symptoms or make full notes of his condition, an out-of-hours GP service was contacted by his parents but did not have access to his full medical records and - perhaps most critically - NHS 111 call operators did not pick up on indications that he was suffering from sepsis. The NHS has underlined the importance of lessons being learned from this tragic case.
I would point out that, from JMW's experience, William Mead's case is far from unique, although perhaps extreme in the combination of errors involved.
If infrastructure, such as NHS 111, exists to provide patients with out-of-hours health support, it should be truly capable and robust. In recent months, there have been far too many complaints that it is not, some of which have been made by individuals working for the helpline.
William's case should make clear the need for instant, full access to the kind of patient information which can determine emergency treatment - and save lives. What is different about this instance is the attention which it has attracted, far more than for other cases of its kind.
As someone who has had to deal with parents bereaved in a similar manner to William Mead's mother and father, I too hope that the report into his death does mark a watershed and that awareness of sepsis and its symptoms and the systems which can collaborate to treat it improves dramatically.