Staff Completed Substandard Notes About Patient’s Surgical Wound That Became Infected

The widower of a pensioner, who died from sepsis after developing a post-operative hospital infection, has called for improvement of standards of care and management after an NHS Trust admitted liability for her death.

Margaret Alley, of West Moors, Dorset, died aged 76, on New Year’s Eve 2015, more than a month after she was admitted to hospital for spinal surgery.

Following her operation at Southampton General Hospital, staff failed to accurately record the appearance of her wound and dressing changes on eight occasions before they realised she was suffering from an infection. By that stage, she had developed sepsis and pneumonia. Margaret died from multiple organ failure. 

Her husband, Robin, is now using World Sepsis Day to raise awareness of the signs of the condition and call on University Hospital Southampton NHS Foundation Trust, which runs Southampton General, to ensure it upholds new guidelines the Trust introduced following his wife’s death.

The Trust admitted liability for Margaret’s death after Robin, 79, instructed specialist medical negligence lawyers at Irwin Mitchell to investigate her care.

Expert Opinion

“The level of care that Margaret received fell way below what patients should expect with devastating consequences.

“Margaret’s case is a tragic example of what can happen when undiagnosed infections are left untreated.

“We work closely with UK Sepsis Trust to raise awareness of the condition and more must be done to educate our doctors so that the signs of sepsis are recognised earlier when the chances of survival are significantly greater.

“Whilst nothing can make up for Margaret’s death we are pleased that the Trust has said it has implemented a number of new procedures. It is vital that the Trust now ensures staff follow these new procedures at all times, so others hopefully do not have to suffer the heartbreak that Margaret’s family has gone through following her death.” Nicole Jackson (née Causey) - Chartered Legal Executive

Margaret, a former restaurant manager, and Robin, a retired construction services manager had been married for 52 years. The couple had two sons and four grandsons

Margaret had been admitted to Southampton General Hospital late on 21 November, 2015, with Cauda equina syndrome - a condition which occurs when the nerves at the base of the spinal cord are squeezed together.

She underwent surgery on 23 November, but was not seen again by her spinal surgeon for almost two weeks following the procedure.

On 3 December, Margaret was diagnosed as having an acute kidney injury caused by low sodium levels in her blood.

Margaret, who also developed pressure sores while an inpatient, started wheezing and her family raised concerns to staff on 12 December.

Three days later, she was found unresponsive in her bed. Scans revealed she had developed sepsis from her infected wound and pneumonia. Margaret underwent surgery to try and remove the infection, and again on 19 December.

However, her condition deteriorated. She was placed on a ventilator and died on 31 December, 2015.

The Trust admitted that Margaret’s nursing records, charting her surgical wound, dressing changes and types of dressing used were ‘substandard’ on eight occasions, between 23 November and 14 December. It also admitted that staff did not accurately complete fluid intake and output forms and failed to comply with fluid restrictions set by clinicians.

The Trust also added that a lack of a spinal wound care plan, monitoring, a lack of accurate records and a failure to escalate Margaret’s condition contributed to her infection, the development of sepsis and subsequent death.

Following Margaret’s death, the Trust said it had introduced new procedures including:
• Spinal patients are reviewed daily by a consultant or senior member of staff
• Reviews are recorded in patient notes
• Training to spot the signs of sepsis and the importance of fluid balance is included in the inductions of health care support workers, newly qualified nurses and overseas staff
• Nursing staff are now expected to escalate families’ concerns about the deteriorating condition of patients.

Robin said: “Nearly three years from Margaret’s death our family still cannot believe she is no longer with us.

“We appreciate that hospital staff are extremely busy but for medical records not to be accurately recorded on so many occasions is astonishing.

“Our family will never get over how Margaret was badly let down by those who were supposed to look after her. The Trust will never understand the emotional toll this has had on our whole family and the never-ending helplessness we all feel in terms of knowing that her death was avoidable.

“All we can hope for now is that Margaret’s death was not in vain and that action is taken to improve training so that this cannot happen again to others in a similar situation.”

World Sepsis Day is September 13 2018. For more information about the condition and symptoms visit the UK Sepsis Trust website.

Read more about Irwin Mitchell's expertise in handling medical negligence cases.