Woman died week after Wrexham Maelor junior doctor failed to spot severe sepsis

A woman died seven days after a junior doctor failed to spot she was suffering from severe sepsis in her leg.

The woman was kept waiting in an ambulance outside Wrexham Maelor hospital for three hours before being told she looked well and then discharged.

She returned to hospital three days later where she was found to have an acute kidney injury.

Her condition worsened and she died four days later.

The Public Services Ombudsman has found the woman, identified only as “Mrs B”, should have been admitted after being first taken to the emergency department on February 3, 2015.

She was taken to hospital after vomiting and feeling pain in her legs – where she had ulcers.

The Ombudsman investigation found the sepsis could have been diagnosed at that stage.

Upholding a complaint by the woman’s family, the Ombudsman’s assistant investigation officer Greg Phillips said: “This has caused an injustice to Ms A (her daughter) and her family as they will be left with the uncertainty of not knowing whether, if treatment had been initiated earlier, the outcome may have been different.”

The Betsi Cadwaladr University Health Board agreed to apologise and pay the family £2,500 “to reflect the uncertainty”.

In addition, the Board was told to remind the junior doctor involved to keep fuller notes of his assessments. They were also instructed to remind emergency department staff of the need to follow good practice in managing cases of sepsis or suspected sepsis.

The family told the Ombudsman the doctor looked at Mrs B’s legs after they asked him to – though he did not recall doing so.

She was discharged at 4am after her symptoms appeared to have settled but the following day district nurses attending her leg dressings were so concerned that she returned to hospital.

The sepsis guidelines were then followed but Mrs B died on February 10.

The health board also apologised for the three-hour delay in an ambulance outside the hospital on her first visit – which the Ombudsman described as “concerning”.

Last week an inquest in Ruthin heard how a 95-year-old Abergele woman was kept in an ambulance outside Glan Clwyd Hospital for nearly four hours after injuring her head in a fall.

At the conclusion, North Wales East and Central coroner John Gittins said that despite measures taken by the Health Board to ease the problem at all three main hospitals he was concerned at the potentially fatal outcome of such delays.

He said he would be writing to the Board, the Wales Ambulance Service, Welsh Government and four local authorities asking what steps were being taken to tackle the problem.

A report to next week’s meeting of the Health Board states that in March there were 384 delays of more than an hour outside the Maelor Hospital, 332 at Glan Clwyd and 140 at Ysbyty Gwynedd – a total of 97 more patient delays than in February.

“Though disappointing, this does demonstrate a significant improvement to the same period last year, where there were 856 delayed patients out of a total of 1,251 arrivals in March, 2016,” says the report.