Mum-Of-Four Readmitted Day After She Was Sent Home
The devastated family of a Lowestoft woman who died from sepsis after being discharged from hospital with a kidney infection are calling for lessons to be learned following an inquest into her death.
Teresa Anderson, from Kessingland, attended James Paget University Hospital (JPUH) during the evening of 11 May, 2020, complaining of a sharp pain in her left side. Following a CT scan she was suspected to have had kidney stones. Following consultation with doctors the mum-of-four and grandmother-of-12 and great-grandmother was discharged in the early hours of 12 May.
By the next day, Teresa started vomiting and was feeling cold and shaking. She was taken to hospital by ambulance but died the following morning - 14 May - aged 60. A post mortem examination stated the cause of death as sepsis (where the body attacks itself in response to an infection) and pyelonephritis which is a severe kidney infection.
Following Teresa’s death, her family including husband Malcolm, 65, instructed medical negligence experts at Irwin Mitchell to investigate her care under James Paget University Hospitals NHS Foundation Trust and support them through the inquest process.
Husband And Medical Negligence Lawyers Issue Sepsis Warning
Malcolm has now joined his legal team in warning of the dangers of sepsis. It comes after a Root Cause Analysis Investigation Report by the Trust stated that Teresa’s death was the outcome of “not receiving antibiotics” during her first hospital admission.
It found a suspected diagnosis of kidney infection was not flagged in a CT scan report. If it had been Teresa’s care plan would have been changed, she would have been kept in hospital and intravenous antibiotics started.
The report said that Teresa, retired, would probably have survived if she had received antibiotics.
No in-patient urology beds at James Paget Hospital allowing for Teresa to be admitted to a ward was also a contributory factor, the report found. If she had been admitted Teresa’s sepsis may have been picked up earlier “and the outcome may have been different,” the report said.
Case During Height Of Covid-19
The case was at the height of Covid-19 pandemic when patients and doctors “were advised on avoiding unnecessary hospital admissions”, the report added.
An inquest at Norfolk coroner’s court concluded that Teresa died from acute pyelonephritis which was not initially diagnosed and treated.
Expert Opinion“It’s been a difficult time for Teresa’s family, having to cope with her death and then relive it during the inquest.
While nothing can make up for their devastating loss, we’re pleased to have been able to help secure the answers they deserve.
Sadly, the inquest and the Trust’s own investigations have identified a number of extremely worrying issues in the care Teresa received following her first admission to hospital.
While medical staff and the health service were under unprecedented pressures at the time of Teresa’s admission, her family believe she would have survived if she had received the care she deserved.
It’s now vital that not only lessons are learned to improve patient safety but that people continue to seek medical advice at the earliest opportunity despite the pressures of the pandemic.
While incredibly dangerous, sepsis can be beaten with early diagnosis and treatment.”
Amie Minns - Solicitor
Malcolm and Teresa were married for 30 years at the time of her death. The couple have three adult children – Jodie, 35, Clint, 44, and Shane, 40. They had another daughter, Natasha, who sadly died around 10 years ago. As a result, Malcolm and Teresa were assigned the sole guardians of their grandson Tye, who was three when Natasha died.
Malcolm, a retired fisherman, said: “The past 15 months have been unbearable. To lose a daughter and now my wife is awful and I still can’t get my head around the fact that Teresa isn’t here anymore; my life will never be the same again.
“Teresa was the best wife and mum, and I still think about her every single day. We had been together for 44 years and did everything together. We were a team and it devastates me to imagine the rest of my life without her by my side.
“Our children are also struggling a lot. Tye has now lost two mums.
“Having to listen how Teresa died at the inquest has been incredibly difficult for us all, but we’re grateful that we now have some answers as to why she was taken from us so soon and unexpectedly.
“While Teresa was consulted about being discharged from hospital we believe the full extent of how she was seriously ill wasn’t explained, preventing her from making an informed decision about what was best. If it was there was no way she would have come home.
“While nothing will ever change what happened, all we can hope for now is that there are changes to help stop another family from suffering the way we have.”
Teresa was brought in to the emergency department by ambulance on 11 May, 2020, with sudden onset of left sided abdominal pain. She was examined, given pain relief and underwent a CT scan of her kidneys, ureters and bladder. The scan report stated no evidence of inflammation and it was thought that Teresa had passed a kidney stone. No antibiotics were administered and she was discharged home on 12 May.
During the early hours of 13 May, Teresa was brought back to the emergency department by ambulance. She was diagnosed with septic shock, acute pyelonephritis and acute kidney injury. She was transferred to the intensive care unit. Her condition deteriorated further and she died during the morning of 14 May.
NHS Report Finds Death Was As A Result Of Not Receiving Antibiotics During First Admission
A Root Cause Analysis Investigation Report from James Paget University Hospitals NHS Foundation Trust stated that Teresa’s death was the outcome of “not receiving antibiotics at first presentation”.
It was also reported that had the CT scan report stated there was pyelonephritis, it would have “changed the management plan and a course of IV antibiotics would have been commenced” and Teresa “would have been admitted under the care of the on-call medical team.”
As a result, a recommendation was made in the report to clinically assess radiology findings. Learning information on pyelonephritis is also to be made available to the emergency department.
During the inquest witnesses for the Trust detailed how their practice had changed since Teresa’s death, including lowering the threshold for prescribing antibiotics where infection is suspected. This is particularly important for patients with additional risk factors, such as diabetes. The Trust are also working with Medica (the company responsible for outsourced radiology) to ensure that there is there is the opportunity for A&E clinicians to discuss findings with the radiologists where required and to include all relevant information on the initial request.
Signs of sepsis include slurred speech, confusion, extreme shivering and muscle pain, passing no urine in a day, severe breathlessness and mottled or discoloured skin.
For more information visit the UK Sepsis Trust website.