Another Devastating Story of Delayed Sepsis Recognition

Share this story

My mother was courageous and incredibly positive despite living with rheumatoid arthritis for 56 years. She rarely complained, had a radiant smile and a ready laugh. Her family was everything and she really loved her newest great grandson (pictured).

At 86 years, her heart wasn’t great, and she had a leg ulcer but was still driving herself around and determined to live independently.

In April 2017, Mum had pain from her leg ulcer. I took her to a hospital near our home in a capital city. She was admitted and a specialist changed her pain medication and devised a plan to help her recover.

On Friday, a week or so later, Mum was noticeably subdued when I visited but I thought she was probably still adjusting to her new medication.

On Saturday, my husband and I visited, and she was initially fine. But she became sleepy as the day progressed. This was unusual for Mum. An ‘on call’ Doctor attended, adjusted Mum’s medication and ordered intravenous fluids.

After he left, Mum developed a grey pallor, and as I watched her breathing, I saw her struggle. I found the Doctor who was on his way out of the ward and told him what I’d observed. He told me he’d review Mum and left the ward.

As the day progressed, Mum became delirious and a nurse explained that delirium was common in the elderly and likely to pass.

On Sunday, Mum was sitting up when my husband and I arrived and then dropped off to sleep. I had trouble finding a nurse to explain that Mum was very sleepy and expressed my concerns. She said she would come in later, but no one arrived.

Later, my husband found a nurse. The nurse tried taking observations and told us that the oxygen and blood pressure monitors weren’t working. We told her we’d like the Doctor to reassess Mum. The nurse mumbled something and went away.

By noon, Mum couldn’t wake for lunch. I was getting worried and told a nurse that Mum was unwell and that I wanted to speak to her supervisor. She said, “I report to the Team Leader who doesn’t come in until Monday.” I asked to speak to a Doctor directly. She told me “You have to wait until Monday when the Doctor comes around.” She turned and walked away from me.

By evening, Mum’s delirium had returned and she was ill.  She felt cool, looked sick and the nurses were not doing anything to assist.

On Monday, my husband and I decided we’d not leave Mum alone until she’d seen a Doctor and was out of danger. At 9 am she mumbled a few words and fell asleep. As the hours passed, her condition deteriorated with her tongue lolling about in her mouth. I suspected she was unconscious.

My husband and I kept reporting Mum’s condition to the nurses who appeared rushed, indifferent and kept telling us we had to wait.  At 11.50am. a Doctor and Trainee arrived and attempted to elicit a response from Mum to no avail. Naloxone was administered with little response.

It took until 16.00 for Mum to be admitted to the Intensive Care Unit (ICU) and diagnosed with ‘septic shock’, ‘hospital acquired pneumonia’ and ‘acute kidney injury’.

We were told to say goodbye to her twice over the next few days.  Mum rallied like a trooper each time. The Hospital told us Mum could ‘go home’. We admitted her to high care in Aged Care in late May and she died in early July. Her death certificate records heart failure and sepsis as causes of death.

Information from three subsequent complaints informed me that junior nurses and  doctors were reluctant to disturb  senior Doctors on weekends. I have not been informed that this was investigated.

The Coroner had an independent medical expert review my mother’s hospital records. Among his comments are the following:

  1. extensive hypotension (low blood pressure) readings over several days and the nausea and vomiting were attributed to medication, however, low blood pressure, lack of oxygen combined with nausea and vomiting should have been a red flag. “I believe the significance of Mrs Flynn’s hypotension and oxygen desaturation were not appreciated … [over several days] … the presence of nausea and vomiting with hypotension should be of particular concern.”
  2. “It is possible that the development of sepsis was … contributing [to her] drowsiness and delirium …”

I write this account of what happened to my mother with the aim of contributing to a better awareness and understanding of sepsis and its signs and symptoms with the hope that it will prevent similar cases in the future.

by Robyn Flynn (Daughter)