Sepsis: investigating under the Patient Safety Incident Response Framework (PSIRF)

Ged’s family kindly wrote the following words about Ged to give the readers of this report a sense of his life, and the person he was.

Ged was born in 1941 in Blackpool after his mum was sent there during the blitz.

As a young man he was a talented sportsman, playing both cricket and football and having trials for Manchester City as a boy.

He became a bricklayer and worked all over Europe and Africa, most notably Sudan where, so struck by the poverty, he gave away all his clothing and belongings when leaving and came home in just the clothes he was wearing.

Although he and his late wife Jean were unable to have children, he spent a lot of time with nieces and nephews, watching them play sport or taking them away on holidays.

He was loved by everyone who met him, from his family and friends to the carers who came to the house every day, or the staff in the nursing home who looked after him when he was there for Jean’s respite.

His bond with his late wife Jean – who herself passed away just 2 months after Ged – was one of total devotion and love, utterly unbreakable. He was a kind, caring, generous and loving man and his loss is still painful for us all to take nearly 12 months on.

Ged had a stroke in 2002 which meant he needed help with everyday living. This was usually provided by his wife, Jean, alongside other carers. Ged went into the nursing home because his wife needed to go into hospital and the lift in their home, which gave access to the bathroom and bedroom, had broken down.

On 4 April 2024, Ged arrived at the nursing home at about 23:00 hours. The next day, nursing staff noted that Ged seemed confused. A urine sample was sent to the laboratory to test for infection in case this was the cause. The urine test came back as negative for infection.

On 8 April 2024, Ged had a high temperature and there were other signs to again suggest he may have a urine infection. That evening, an out-of-hours GP was contacted who prescribed antibiotics and, in line with their usual practice, sent the antibiotic prescription to the local pharmacy for collection. This presented a problem as the medicine policies followed by the nursing home stated that medicines should be prescribed on its electronic patient record system. The out-of-hours GPs were not familiar with, and did not prescribe on, this system.

On 9 April 2024, Ged’s antibiotics were collected from the pharmacy in the morning. Attempts were made to get staff at the hospital to get the antibiotics prescribed on the nursing home’s electronic patient record system, but this was not achieved during the day. Because of this, and, in line with policy, nursing staff did not give the antibiotics to Ged. At 19:44 hours the antibiotics were prescribed on the electronic patient record system and Ged was given his first dose at 20:00 hours. That evening Ged became more unwell, and nursing staff were concerned he may be developing sepsis.

On 10 April 2024, an ambulance was called at 00:50 hours and Ged was taken to the hospital. Ged was seriously unwell on arrival at the hospital and was diagnosed with sepsis. Treatment was started but Ged’s health did not improve. He died at 19:30 hours that day.

The investigation found that:

• Blood tests and other clinical markers when Ged arrived at the hospital met the criteria for a diagnosis of sepsis. The care and treatment he received at the hospital for sepsis was in line with national and local guidance.
• Ged’s NEWS2 score (a scoring tool that helps identify if a patient’s health is deteriorating) rose at the nursing home which indicated that he was becoming unwell, most likely due to a urine infection.
• Ged’s confusion at the nursing home was not scored as ‘new’ on the NEWS2 tool and his family’s concerns about his confusion were not documented or acted on. Staff were unclear whether Ged’s confusion was a response to the circumstances of his arrival in an unfamiliar environment or an indication that he may be becoming unwell.
• Medical care arrangements for the nursing home included a GP practice, an out-of-hours GP service, and nominated doctors at the hospital. The different responsibilities for medical care created challenges for nursing staff.
• GPs at the GP practice were not familiar with prescribing on the electronic patient record system used by the nursing home and the system was not used by GPs at the out-of-hours GP service.
• The medical care arrangements meant that patients may be prescribed medicines out of hours that were not on the nursing home’s electronic patient record system.
• Getting a medicine prescribed by an out-of-hours GP on the electric patient record system or written on a medicines administration record by a clinician trained to do so, was not easy and took time. It involved multiple telephone calls, to multiple staff at the hospital and/or GP practice.
• The medicine policies that the nursing home staff were expected to comply with stated that medicines should be prescribed on the electronic patient record system before being given to a patient. An alternative was for prescribed medicines to be copied onto a paper medicines administration record, but the nurses had not received training to do this.
• The challenge of getting Ged’s antibiotics prescribed on the nursing home’s electronic patient record system resulted in him receiving his first dose of antibiotics nearly 20 hours after they were originally prescribed.
• The new process put in place following this event to manage out-of-hours prescriptions is not well understood by staff. In addition, it involves multiple steps and communications across teams which creates a risk of delays in care and treatment.

The investigation identified three areas of improvement which the nursing home and hospital could develop safety actions to address.

Sepsis is a life-threatening condition that happens when the body’s response to an infection injures its own tissues and organs (Singer et al, 2016).

Sepsis is the main cause of death from infection, especially if it is not recognised and treated promptly (Singer et al, 2016). There are varying estimates of the number of deaths from sepsis. The UK Sepsis Trust states that there are up to 48,000 sepsis-related deaths in the UK each year (The UK Sepsis Trust, n.d.). The Office for National Statistics, which collects data from death certificates, recorded 26,203 sepsis-related deaths in England and Wales in 2023 (Office for National Statistics, 2024). Some people can potentially survive sepsis if they have the right treatment in a timely manner (Academy of Medical Royal Colleges, 2022; Singer et al, 2019).

There have been initiatives to improve the recognition and timely treatment of sepsis over the last 20 years, yet it has persisted as a safety risk. Furthermore, the themes from incidents and complaints involving sepsis have remained largely the same over time (Parliamentary and Health Service Ombudsman, 2023).

Sepsis is not a specific illness. The diagnosis is based on a number of signs and symptoms in a patient with suspected infection (Singer et al, 2016). Sepsis can be difficult to diagnose even for experienced clinicians because:

• the signs of sepsis can be vague and can mimic other illnesses, particularly in the earlier stages of the condition
• there is no single sign that uniquely points to sepsis
• there is no single diagnostic test to confirm or rule out sepsis
• there is no one predictive tool or set of clinical decision rules that has been evidenced to reliably determine who has sepsis
• symptoms can show differently in different people, depending on their age, immune system, underlying health conditions, medications they take and the source of their infection. (National Institute for Health and Care Excellence, 2024)

Yes. People in the following groups are at more risk of developing sepsis:

• the very young (under 1 year old)
• older people over 75 years or who are frail
• people with diabetes
• people with a weakened immune system such as those having chemotherapy treatment
• people with a genetic disorder that affects their immune system, such as people with Down’s syndrome or sickle cell disease
• people who have recently had surgery or a serious illness
• people who have given birth, had a miscarriage or termination of pregnancy in the past 6 weeks. (National Institute for Health and Care Excellence, 2024; NHS, 2022)

Yes. The National Institute for Health and Care Excellence (NICE) published guidance on the recognition, diagnosis and early management of suspected sepsis in 2016 and this was updated in 2024. The Academy of Medical Royal Colleges (AoMRC) published a statement on the antibiotic treatment of sepsis in 2022. The UK Sepsis Trust has also published resources and tools to help with the recognition of, and response to, suspected sepsis.

NICE (2024) and AoMRC (2022) guidance highlights the importance of finding the source of any infection and taking action to control it. Sometimes control is achieved by antibiotic treatment; other times a surgical or drainage procedure may be needed in addition. Both NICE and AoMRC recommend the use of a tool called the ‘national early warning score’ (NEWS2) to assess the risk of severe illness or death from sepsis.

NEWS2 is a scoring tool developed by the Royal College of Physicians (2017). The tool was not developed specifically for sepsis, but rather to help improve the recognition of, and response to, patients who are becoming more unwell whatever the cause. NICE guidance states that NEWS2 should be used to support clinical decision making, not to replace clinical judgement. This means that a patient’s history, the findings from any physical examination, and any other reasons for concern must also be taken into account. Although there is evidence to support the use of NEWS2 in the context of sepsis (Inada-Kim, 2022), NICE (2024) states that further research is needed.

Using the NEWS2 tool involves giving a number to vital signs, or parameters, that are routinely measured when a patient is in hospital or a setting where their health is being monitored. The six vital signs are:

• respiratory (breathing) rate
• oxygen saturation (the amount of oxygen in a person’s blood)
• temperature
• blood pressure
• pulse rate
• consciousness.

The number given to each vital sign is based on how far outside the expected range it is; the higher the number the more the vital sign varies from the norm. The numbers are then added up to give an overall score. Two points are added to the score for people who need oxygen to maintain their recommended oxygen saturation (see figure 1). The total score is used to indicate the person’s risk of severe illness or death (see figure 2), prompt any actions to be taken, and decide the frequency of monitoring.

Figure 1 The NEWS2 scoring system (Royal College of Physicians, 2017)

Consciousness is assessed according to the following descriptors:

• alert
• new confusion (C)
• responds to voice (V)
• responds to pain (P)
• unconscious (U).

Figure 2 NEWS2 scores and risk of severe illness and death (Royal College of Physicians, 2017)

The nursing home and the hospital involved in Ged’s care used NEWS2 and their policies for monitoring and escalation of adult patients who are becoming more unwell reflect NICE (2024) guidance.

In its statement on the initial antibiotic treatment of sepsis, AoMRC included a framework to help clinicians in their decision making and initial evaluation of sepsis. The framework linked NEWS2 scores to timeframes for actions to be taken and antibiotics given (see figure 3). AoMRC also recommended that research be carried out to evaluate the use of NEWS2 to guide the initial evaluation of sepsis.

Figure 3 Decision support framework to help clinicians with their initial evaluation of sepsis in adults 16 years or older (Academy of Medical Royal Colleges, 2022)

Most NHS hospitals have electronic patient records. Sepsis alerting tools have been developed that can be incorporated into these records to produce an automated alert in response to set triggers. Most sepsis alerts in NHS hospitals are based on NEWS2 (Honeyford et al, 2023). There is not yet enough evidence to confirm whether they help improve care for patients with possible sepsis (Academy of Medical Royal Colleges, 2022). The nursing home and the hospital involved in Ged’s care did not have electronic sepsis alerts but did have built-in prompts for staff based on NEWS2. For example, if a patient’s NEWS2 score was 5 there was a prompt to arrange an urgent clinical review of the patient.

Yes, there is a link. Urine infections are common, and typical symptoms include needing to pass urine more often and/or more urgently than usual; pain or a burning sensation when passing urine; and urine that looks cloudy and/or smelly. Urine infections can usually be treated effectively with antibiotics. However, sometimes an infection in the urinary passage can spread and cause sepsis. Although the link between urine infections and sepsis is well known, it is not fully understood why some people develop sepsis and others do not (The UK Sepsis Trust, n.d.; Thornton et al, 2018).

National guidance details the diagnosis and antibiotic treatment of urine infections (Public Health England, 2020; National Institute for Health and Care Excellence, 2025; National Institute for Health and Care Excellence, 2018). Ged was prescribed antibiotics in line with the national guidance.

Thursday 4 April 2024

Ged arrived at the nursing home at about 23:00 hours, after being assessed in the hospital’s emergency department. He had weakness on his left side from a stroke in 2002 and used a wheelchair. Ged usually lived with his wife, Jean, who, alongside paid carers, helped him with activities of daily living. Jean needed to go into hospital and the lift in their house had broken down which meant Ged could not get to the bathroom or his bedroom. Ged’s nephew Nick, and Nick’s partner Maggie, had spent the day trying to arrange for Ged to go into the nursing home. Ged had been there in the past to give his wife a break from caring, so he, and his family, knew the home. However, despite Nick and Maggie’s best efforts, they had to take Ged to the emergency department for help. After assessment in the emergency department, and confirmation that Ged had no medical needs, liaison took place with the nursing home resulting in, Ged’s stay there being agreed.

In the emergency department, and on arrival at the nursing home, it was noted that there were no concerns about Ged’s health. The reason for Ged being in the nursing home was purely because of his home situation.

Friday 5 April 2024

Nursing staff noticed blood in Ged’s urine, and that he seemed confused. They documented these findings along with their uncertainty about whether Ged’s confusion was normal for him or whether it was new. It was thought Ged’s confusion was possibly the result of him having arrived late the previous night into an unfamiliar environment. Another possibility was a urine infection, and a nurse used a special urine testing strip or ‘dipstick’ to aid her assessment of this. The nurse wanted to discuss Ged and the urinalysis result with a doctor, so they contacted the GP practice which provides medical care to patients in the nursing home during the day. As Ged’s stay at the nursing home was not a planned event, he had not yet been registered as a patient with the GP practice, so they had no details about him.

The nurse then tried to speak to a resident doctor at the hospital. The nursing home is linked to the hospital and a limited amount of medical input is given to patients in the home by two designated consultants and a resident doctor. However, the resident doctor was not in the hospital. The doctor spoken to advised the nurse to send a urine sample to the hospital laboratory to test for infection. Ged’s temperature, pulse, blood pressure and heart rate were all within normal range; his NEWS2 was documented as 0 (see ‘Background and context’ section).

Saturday 6 April and Sunday 7 April 2024

Over the weekend staff documented that Ged continued to be confused at times, particularly at night. This change in mental state was noticed by Nick and Maggie who visited him each day, and by Ged’s wife, Jean, who spoke to Ged on the telephone on Saturday. Apart from this change in mental state, there were no other clinical signs that Ged was becoming unwell that weekend and his NEWS2 was documented as 0.

Monday 8 April 2024

The laboratory result of Ged’s urine sample was available at 10:27 hours and no infection was found. However, Ged’s urine was noted to be very concentrated that evening and on occasions he was incontinent of urine. His temperature was raised (38.2 Celsius) when a nurse took it at 22:18 hours. Concerned about the possibility of infection, the nurse tested Ged’s urine with a dipstick and the results this time were more suggestive of infection than they had been the previous Friday.

At around midnight the night staff rang the out-of-hours GP service and discussed the new clinical signs and ongoing periods of confusion with a GP. The GP prescribed antibiotics as it was likely Ged had a urine infection. In line with usual practice for the out-of-hours GP service, the GP sent the antibiotic prescription to the local pharmacy for collection in the morning. The GP also advised that if Ged’s temperature did not come down, or if he was not able to take fluids, or started to vomit, they should call an ambulance to take Ged to hospital. Ged was given paracetamol to help bring his temperature down and he settled to sleep.

The GP’s prescription created a problem as the policies followed by the nursing home stated that medicines must be on its electronic patient record system before being given to patients. The out-of-hours GPs were not familiar with, and do not prescribe, on this system. The only alternatives to this in the policies were that, in exceptional circumstances, a medicine could be prescribed on a paper medicine administration record, or, if there was an existing prescription, this could be copied onto a paper medicine administration record or the electronic patient record system. Only staff with specific training and authorisation to do so could copy existing prescriptions.

Tuesday 9 April 2024

Ged’s antibiotics were prescribed at 00:26 hours by the out-of-hours GP. At 06:03 hours that morning Ged’s blood pressure was low, and his NEWS2 was documented to be 2. Ged’s blood pressure returned to normal during the day. The antibiotics were dispensed by the pharmacy and delivered to the nursing home. However, in line with policy, nursing staff wanted to get them prescribed on the electronic patient record system before administering them to Ged. Staff rang the hospital on two occasions during the day to see if a doctor would prescribe the antibiotic onto the system. The designated resident doctor who provided medical input to the nursing home was not at work that day and the antibiotics did not get prescribed on the system.

When the night staff came on duty at 19:00 hours they were told about the situation. One of the staff nurses had previously worked in the hospital and thought the pharmacist on duty may be able to help. They telephoned the pharmacist who then contacted the out-of-hours GP service and obtained details of the prescription and documentation by the GP. With this information, they agreed to copy the prescribed medication onto the electronic patient record system so Ged could be given his antibiotic.

Ged was given his first dose of antibiotic at 20:00 hours. After taking the antibiotic he vomited and staff were concerned that he was becoming very unwell. His heart rate was increasing, he felt ‘hot to touch’ and he had a high temperature. Nursing staff were unable to bring Ged’s temperature down despite giving paracetamol, using a fan and opening the window. His NEWS2 score was recorded as 2.

Wednesday 10 April 2024

The staff nurse caring for him documented their concern that Ged ‘may well develop sepsis’ and at 00:50 hours they rang 999 to ask for an ambulance to take Ged to the hospital.

Ged arrived at the emergency department of the hospital at 02:11 hours. The paramedic who assessed Ged had alerted the emergency department that they were on their way and that they thought Ged had sepsis. They had given Ged intravenous fluids (fluids given through a thin tube into one of Ged’s veins) and oxygen in the ambulance alongside monitoring him.

A resident doctor met Ged on arrival. Ged had become seriously unwell in the last few hours. His NEWS2 score at 02:19 hours was 12 due to his abnormally high temperature (39.5 Celsius), high respiratory and heart rate, abnormally low blood pressure and low oxygen saturation (see ‘Background and context’ section). These signs were all in keeping with sepsis given Ged’s likely urine infection.

Ged was prescribed treatment for sepsis which was in line with national and local guidance, and he was referred to the medical team for his ongoing care. Treatment included intravenous antibiotics (antibiotic given through a needle into one of Ged’s veins). This was prescribed at 02:59 hours and given at 03:20 hours. It was also documented that, after discussion with Ged, and given his underlying state of health, it would not be appropriate or in his best interests to try more invasive treatments.

Ged was reviewed by a consultant from the medical team at 09:11 hours that morning. The consultant documented that despite treatment Ged’s health was not improving – in particular, his blood pressure remained abnormally low. The plan made was to continue the current treatment (antibiotics, intravenous fluids and oxygen therapy) but to be aware that Ged may be nearing the end of his life. The consultant prescribed medications to help ensure Ged’s comfort if he had pain or became distressed.

During the course of the day Ged remained severely unwell and he died at 19:30 hours.

An incident report was submitted by a nurse at the nursing home on 12 April 2024. The incident report raised concern about the delay in Ged getting his antibiotics and said this had resulted in him getting unwell and needing to go to hospital. The report stated that although the antibiotics had been received from the local pharmacy, they ‘could not be given’ as they were not on the electronic patient record system. The report stated there had been ‘numerous attempts’ by nursing staff to get the antibiotics put on the electronic patient record system. The incident was discussed at a patient safety meeting that week. Senior staff who attended the meeting agreed there should be a rapid review of events; this was carried out by the lead nurse for the nursing home.

On 17 April 2024, the rapid review was discussed at the patient safety meeting. Based on the findings, it was decided that a full patient safety incident investigation (PSII) should be carried out. HSSIB was told this decision was because one of the agreed priorities for the larger organisation which the nursing home belongs to, is understanding whether there are opportunities for improvement in the care of patients who become more unwell while in one of their hospitals or community services.

In line with expected practice for NHS organisations, the incident and planned investigation was recorded on the NHS incident database in use at that time. HSSIB reviewed this database as a source of information about patient safety issues. After reading the details of the event on the database, a meeting took place between HSSIB and the associate director of governance and other senior staff from the organisation. After discussion, it was agreed that Ged’s experience would be the focus of one of three HSSIB investigations about sepsis. The hospital and nursing home worked with the HSSIB team during the investigation.

The draft report was shared for comments with all those affected by the event including Ged’s nephew, Nick, and staff involved either directly or indirectly in Ged’s care. These people will also receive a final copy of the report once it has been approved by HSSIB. Progress on safety actions to address the areas of improvement included will be monitored by the relevant safety leads in the nursing home and the hospital.

The terms of reference for this investigation were informed by the concerns shared by Ged’s nephew Nick, and Nick’s partner Maggie, during the investigation’s first meeting with them. Key staff involved in Ged’s care, either directly or indirectly, also helped to shape the areas of focus.

This investigation will:

• explore whether Ged had signs or symptoms of sepsis at the nursing home
• explore the factors that influenced the prescribing and administration of Ged’s antibiotics
• identify opportunities for improvement in the timely administration of antibiotics for patients with suspected infection.

Further details about the terms of reference, and how the investigation addressed these, can be found in appendix 1.

The investigation gathered information from multiple sources and sought different perspectives on events. The investigation considered how factors such as the environment, equipment, tasks, policies and organisational culture influenced the decisions and actions of staff. Information sources included:

• Ged’s nephew Nick, and Nick’s partner Maggie
• staff directly or indirectly involved in Ged’s care
• Ged’s clinical records
• national and local guidelines about sepsis
• articles and research about sepsis.

The investigation used a number of methods to help organise, understand and analyse the information gathered. Methods included:

• developing a timeline to help make sense and create a narrative understanding of events
• creating a map of all the relevant organisations, at different levels of the healthcare system, from government to hospital, to illustrate how these related to the activities of staff
• using a framework (called the Systems Engineering Initiative for Patient Safety (SEIPS)) to inform information gathering and help examine the data gathered; the framework prompts investigators to consider how work factors such as the environment, equipment, organisational policies and procedures interact to influence the actions and decisions of staff (see appendix 2)
• developing themes from analysis of the information gathered to help understand and explain why things happened in the way they did
• application of NHS England’s Safety action development guide (NHS England, 2022) to inform thinking about the development of areas of improvement and safety actions
• use of an evidence log to document the information sources used to inform the investigation.

The nursing home and hospital are both part of the same organisation. Most of the patients at the nursing home have neurological conditions and are known to the neurology team at the hospital; some will have received care from the neurology team over months or years. Most of these patients are in the nursing home to give their families a break from caring duties. The nursing home has a small number of beds for patients without neurological conditions or complex needs and who, like Ged, need a short period away from their usual home and care arrangements.

The medical care arrangements for the nursing home are as follows:

• between 08:00 and 19:00 hours GPs from the GP practice provide medical care
• between 19:00 and 08:00 hours GPs from an out-of-hours GP service provide medical care
• two consultants from the neurology team at the hospital assess patients as suitable for admission to the nursing home and carry out a monthly review of patients there
• a resident doctor supports the two consultants with the medical input they provide to patients in the nursing home. This support includes ensuring that the regular medicines of any patients going to stay at the nursing home, or requested by the neurology consultants while they are there, are prescribed on the electronic patient record system.

The investigation was told by nursing staff about the challenges to timely treatment created by the arrangements for medical care. Nurses explained the series of steps involved – which each take time – when a patient is unwell during the day and needs a doctor.

The first step is to speak to the receptionist at the GP practice, which takes time. The next step is to wait for a call back from a GP or other clinician. Then, if they speak to a GP, nurses said it was not uncommon for the GP to redirect them to the neurology doctors at the hospital if the patient had a neurological condition and was known by the neurology team. Comments heard were summed up by one nurse who described it as “a mish mash of medical care”. Describing the effect of the medical care arrangements, another nurse said: “We go back and forth … it’s a constant problem … each [GPs at the GP practice, and doctors at the hospital] saying ‘it’s not for us’.” The nurse continued: “It’s very frustrating … we just want to speak to someone and to get an answer for the patient.” The investigation witnessed this situation in progress when visiting the nursing home to meet with staff.

The investigation spoke with the lead GP at the GP practice. They said that the complex needs of most of the patients at the nursing home required specialist knowledge and experience which the GPs at the GP practice did not have. They explained that the GP practice provided medical care to nursing and care homes and the skillset of the GPs was in the medical treatment of health issues related to ageing, not problems associated with neurological conditions or brain injury. Commenting on the nursing home, the lead GP said: “Is [the nursing home] really a nursing home or a hospital ward? If it’s really a nursing home, why is there input from hospital doctors … they are really hospital patients.” The GP spoke about the safety risks inherent in the situation: “We don’t know the patients or their history … they have lots of medical issues and as primary care GPs we are not geared to that … it is not safe … it makes us feel very anxious … lots can go wrong.”

Ged did not have complex needs and was not under the medical care of the hospital for a neurological condition. He was, therefore, more typical of the patients cared for by the GP practice. However, challenges arose because he was transferred directly to the nursing home from the hospital’s emergency department. People usually stay at the nursing home after a period of planning and assessment. The nurse manager of the nursing home said that in her 10 years of working there she had not known a patient come directly from the emergency department as Ged had done. The usual planning period involves a review of the person’s medical and nursing needs, as well as registering them as a temporary patient with the GP practice in case they need medical care while at the nursing home.

Due to the difficulties Ged’s nephew and his partner Maggie had experienced trying to get Ged admitted to the nursing home, he did not arrive until about 23:00 hours. The next day the necessary paperwork, which included a summary of Ged’s health issues and regular medications, was completed and sent to the GP practice. The administration team at the practice are responsible for registering those at the nursing home as temporary patients with the GP practice and uploading the information provided onto the practice’s patient record system. This registration process had not happened by the time nursing staff rang to speak to a GP, that same day, to discuss Ged’s confusion and urine dipstick result. Nursing staff then rang the hospital to speak to the resident doctor who gives medical input to patients at the nursing home. The resident doctor was not on duty and the doctor spoken to explained that they were not involved with patients at the nursing home so could not give medical advice about Ged. However, based on the information given, they suggested that a urine sample be sent to the laboratory to test for infection.

Reflecting on the arrangements for medical care, nursing staff at the nursing home explained that repeated phone calls to different areas, and to different personnel, to try to speak to a doctor takes time – time away from patient care. In addition, it can lead to delays in patients being assessed and started on treatment in a timely way. These challenges are compounded when a prescription for medicine is needed, especially out of hours.

The information gathered indicates an area of improvement which the nursing home, the hospital and relevant stakeholders could develop safety actions to address.

Policies that the nursing home staff are expected to comply with state that medicines should be prescribed on the electronic patient record system. The system used by the nursing home is different to that used by other nursing or care homes where the GP practice and out-of-hours GP service provide medical care. This is because the nursing home is linked to the hospital and both organisations use the same system. The GP practice also has access to this electronic patient record system. However, being able to access a system is different from being able to use it, and different again from being able to use it with confidence and ease. The lead GP at the GP practice said that the three GPs working at the GP practice could access the system and two out of the three could prescribe on it. However, the lead GP said that none of the GPs are familiar with the system as it is not the one that they use day in and day out. The system is only used to prescribe medicines for patients in the nursing home, which does not happen often. The lead GP explained that the interface and functionality of the system differed to those they usually prescribed on. This, coupled with the fact that they do not frequently prescribe for patients at the nursing home, meant “it’s always a long winding way for us when we prescribe on the system”.

Comments by the lead GP were reflected in those by the unit manager of the nursing home. They said that some GPs say “they can’t prescribe” and it seemed that “they don’t like to do it”. As a result, if a prescription is needed for a patient, the resident doctor at the hospital who provides medical input to patients at the nursing home was their “go-to”. If that doctor was not on duty, they would try to get another doctor on the neurology ward to help them. Unlike the GPs, the hospital doctors are familiar with the electronic patient record system as they use it to prescribe medicines for patients in the hospital.

Between 19:00 and 08:00 hours an out-of-hours GP service provides medical care to the nursing home. GPs who work for the out-of-hours service do not use the electronic patient record system used by the nursing home. The usual process is that prescriptions by the out-of-hours GPs are sent (electronically) to a local pharmacy which dispenses the medicine for collection. The medicine policies which nurses at the nursing home are expected to comply with are also used in the hospital. These policies say that medicines should be prescribed on the electronic patient record system before being given to patients. This provides a clear and auditable record of medicines prescribed and administered. In hospital, medicines are provided by the hospital’s pharmacy team who have access to the electronic patient record system. In the nursing home, medicines are usually provided by local community pharmacies although, on occasions, they may be provided by the hospital pharmacy.

The policies describe alternative ways to administer medicines not prescribed onto the electronic patient record system. These are to be used in ‘exceptional circumstances’ and ‘the patients’ best interest’. The alternatives are for a medicine to be prescribed on a paper medicine administration record, or, if there is an existing prescription, this can be copied onto a paper medicine administration record or the electronic patient record system. Only staff with specific training and authorisation to do so can copy existing prescriptions (Medicines Policy, 2023; Medicines Transcribing Policy for Community Services, 2023). In addition, in line with the policies, medicine copied onto a paper medicine administration record need to be checked by a second, trained person. Training has not been given to nurses in the nursing home to enable them to copy a prescription. As stated in the section above, it is not usual for patients to need medicine prescribed during their short stay at the nursing home. In addition, the lead nurse and unit manager suggested that more junior staff might not feel confident or have the experience to support them in doing this.

The requirements in the medicine policies create potential treatment delays for patients in the nursing home. When antibiotics are prescribed to treat an infection, it is important that they are administered in a timely way given the risk of sepsis. Patients at the nursing home who are older and/or frail are at increased risk of sepsis. If a patient is thought likely to have an infection and their NEWS2 score is 1 to 4, the Academy of Medical Royal Colleges’ statement (2022) says antibiotics should be given in under 6 hours. Ged’s NEWS2 score was recorded as 2 on the morning of 9 April 2024 (and the previous night). The rise in Ged’s NEWS2 scores indicated that Ged was becoming unwell with his likely urine infection. Ged’s NEWS2 score was also miscalculated at this point, and this is explained in more detail below in the section ‘Response to clinical signs of infection and Ged becoming unwell’.

Nursing staff described to the investigation the process they follow to get a medicine that has been prescribed by a GP from the out-of-hours GP service put on the electronic patient record system. They said they usually contact the resident doctor in the hospital who is involved with the nursing home and ask them to prescribe the medicine on the system. If the resident doctor is not working, they will see if another doctor working on the neurology ward will do this to help them. The unit manager said that some doctors were willing to do this – particularly if they knew the nursing home and the problems with getting medicines on the electronic patient record system. The other option would be to telephone the GP practice and ask to speak to a GP. As detailed in the section above, they would then wait for a GP to call them back so they could explain the problem and see if they were able to prescribe the medicine on the system. This may or may not be possible depending on the GP and whether they were able to prescribe on the electronic patient record system. Given the difficulties of this route, contacting the hospital was the option tried first. In addition to the task of getting the medicine put on the system, nursing staff must arrange for medicine prescribed out of hours to be collected from the local pharmacy.

Ged was prescribed antibiotics for his likely urine infection by an out-of-hours GP. The antibiotics were collected from the local pharmacy and brought to the nursing home about mid-morning on 9 April 2024. The nurse looking after Ged from 13:00 hours that day was not a regular member of staff at the nursing home. They usually worked in the hospital and on the same ward as the resident doctor involved with the nursing home. The nurse was working at the nursing home to cover for the rostered regular member of staff who was off sick. Although not a regular member of staff, the nurse had worked at the nursing home many times before.

The nurse remembered being told by the unit manager at the start of their shift that Ged’s antibiotics had arrived and needed to be prescribed on the electronic patient record system and then given to Ged. The agreed action was to ring the hospital neurology ward and ask a resident doctor to do this. The nurse said they could not remember ever having faced a situation like this before at the nursing home. Two conversations were documented by the nurse with the ward they usually worked on asking for a resident doctor to prescribe Ged’s antibiotic onto the electronic patient record system. The resident doctor involved with the nursing home was not on duty and the one who was working on the ward had no knowledge of Ged or the nursing home and was busy with other patients. The nurse could not remember Ged or how he seemed that afternoon. However, their documentation from that day showed that Ged’s heart rate, blood pressure and other markers taken at 14:37 hours that afternoon were all within normal range so would not have been a cause for concern.

The unit manager of the nursing home finished their shift at 15:00 hours. At that time, the nurse looking after Ged had phoned the ward and left a message with one of the nurses about the need for antibiotics to be prescribed on the electronic patient record system. The unit manager left their shift with the expectation that the prescription would be on the system that afternoon and Ged would be given his antibiotics.

When the night staff came on duty at 19:00 hours, the option of contacting the hospital pharmacist was suggested by one of the night nurses. They were aware of this option because they had worked in the hospital and knew there was a pharmacist on duty at night. Hospital pharmacists are familiar with the electronic patient record system and have training to enable them to copy existing prescriptions. Although not involved with patients at the nursing home, the pharmacist knew the importance of Ged having his antibiotics so agreed to help. After obtaining details of the prescription from the out-of-hours GP service, the pharmacist copied the prescription onto the electronic patient record. Ged had his first dose of antibiotic at 20:00 hours, nearly 20 hours after it had been prescribed and as a result of nursing staff going outside of normal processes to achieve this.

The bacteria found in Ged’s urine was sensitive to the antibiotic he had been prescribed by the out-of-hours GP. The same bacteria were found in Ged’s blood indicating that his urine infection was the cause of his sepsis. The investigation asked two consultants, one of whom was a microbiologist, about the effect of the delay in antibiotic treatment. Both said it was “impossible to know” as there are many variables in how patients respond to antibiotics. Both pointed out how rapidly Ged had become seriously unwell and that at the point of arriving at the hospital he had needed an intravenous antibiotic for sepsis.

The investigation was told by the lead nurse that in response to this incident a new process had been agreed to enable medicines prescribed for patients at the nursing home out of hours to be prescribed on the electronic patient record system. This process involves nursing home staff contacting one of the clinical teams that works in the hospital at night who would then liaise with the GP who works in the emergency department. This GP can access the out-of-hours GPs consultation records and can also prescribe on the hospital’s electronic patient record system. The investigation found that the nurses interviewed were not clear about the new process, indicating that further work was needed to embed the process to raise awareness and understanding. In addition, the new process involves multiple steps and communications between clinicians which risks delays in care and treatment.

The information gathered indicates an area of improvement which the nursing home and the hospital could develop safety actions to address.

Blood tests and other clinical markers at the time Ged arrived at the hospital’s emergency department met the criteria for a diagnosis of sepsis (Singer et al, 2016). Prior to the ambulance being called, Ged’s documented NEWS2 score and staffs’ assessment of him did not indicate that Ged had sepsis or was at high risk of severe illness and death.

The one consistent clinical sign throughout Ged’s stay at the nursing home was confusion. This was documented by staff and raised as an issue by Ged’s family who felt their concerns were “ignored”. There can be many reasons for a person to be confused. In an older person, changes in environment, particularly if they are unexpected and the environments are unfamiliar, are a common cause of confusion.

Ged arrived at the nursing home late at night and had been in the hospital’s emergency department before that. The nurse caring for Ged when he arrived at the nursing home did not know Ged and thought these events might be the cause of his confusion. The nurse also noted blood in Ged’s urine which, together with his confusion, made them consider the possibility of a urine infection.

Confusion is an important sign in the assessment of a patient’s health. National guidance on NEWS2 states that ‘new confusion’ in a patient should be given a score of 3 (see ‘Background and context’ section). The local observation policy covering the nursing home reflects national guidance. The local policy states ‘if it is unclear whether a patient’s confusion is new … the confusion should be assumed to be new unless otherwise confirmed’. Both national guidance and the local observation policy state that if a single parameter or vital sign gives a score of 3 this should prompt an ‘urgent’ review of the patient ‘by a clinician or team with competence in the assessment and treatment of acutely ill patients’ (Royal College of Physicians, 2017).

Ged’s confusion was not given a score of 3 as there was uncertainty about whether it was a response to the events of the previous night and having arrived late in an unfamiliar environment. This meant Ged did not receive an urgent review by a clinician or team and his NEWS scores from this point forward did not include a score of 3 to reflect his confusion. Nonetheless, the nurse took action and contacted a doctor as they were concerned about the possibility of infection. On the doctor’s advice, a urine sample was sent to the hospital’s laboratory to test for infection (no infection was found).

Over the weekend, Ged continued to be confused at times, particularly at night. There were no other clinical signs or symptoms of concern. His NEWS2 score was recorded as 0 but Ged’s family were concerned about his confusion. They recalled a telephone conversation they arranged that weekend between Ged and his wife, Jean, who also immediately picked up on the change in Ged. Ged’s nephew Nick, and Nick’s partner Maggie, remembered discussing Ged’s confusion with nursing staff and telling them this was not usual for him. Staff interviewed could not remember conversations with Ged’s family about this. However, they were concerned to understand the cause of Ged’s confusion and they pursued the possibility of it being related to a urine infection.

On Monday 8 April 2024 Ged had new clinical signs which, put together, pointed to a urine infection. The signs were:

• concentrated urine
• urine incontinence
• high temperature (38.2 Celsius) at 22:18 hours
• low oxygen saturation (95%) at 22:18 hours
• urine dipstick results which indicated the possibility of infection.

Ged’s NEWS2 was scored as 2 at 22:18 hours because his temperature was raised, and his oxygen saturation was below the expected range. Although the scoring did not account for Ged’s confusion, nursing staff contacted the out-of-hours GP because of their concern that he had an infection, and they gave Ged paracetamol that evening to help lower his temperature. At 23:05 hours both Ged’s temperature and oxygen saturation had returned to within expected ranges.

On 9 April 2024 Ged’s clinical signs remained the same. This was in keeping with the fact that his likely urine infection remained untreated because nursing staff were waiting for the antibiotics to be prescribed on the electronic patient record system. There was one new sign of concern that morning at 06:03 hours, which was Ged’s low blood pressure. Ged’s blood pressure returned to within the expected range by the afternoon. That evening, Ged developed new clinical signs:

• his temperature rose despite paracetamol being given and other efforts to bring it down (using a fan, opening the window)
• his heart rate increased
• he vomited
• his skin felt hot to touch.

Ged’s NEWS2 was scored as 2 at 23:27 hours. Again, although the NEWS2 scoring did not account for his confusion, nursing staff acted on these new signs which indicated that Ged was becoming more unwell with his infection. They contacted the ambulance service at 00:50 hours and stated their concern that Ged was developing sepsis and needed to be taken to hospital.

Ged’s NEWS2 was scored as 2, at most, while he was in the nursing home indicating that he was at low risk of severe illness and death (see ‘Background and context’ section). However, these scores did not include Ged’s new confusion which would have increased the scores to reach 5 on three occasions. A score of 5 meant that Ged’s care should have been discussed with a GP for urgent advice. In this event, staff did contact a GP to discuss Ged’s care despite the NEWS2 scoring not accounting for his confusion and Ged was prescribed antibiotics. However, Ged’s care highlights the importance of recognising and scoring new confusion in NEWS2 and of involving a patient’s family to support staff in their assessment of confusion.

The information gathered indicates an area of improvement which the nursing home and the hospital could develop safety actions to address.

The investigation will:

Appendix 2 key interactions

Extract from the organisation’s adult National Early Warning Score (NEWS) observation policy showing how community staff should respond depending on a patient’s NEWS score.