Son's complaint over father's sepsis death upheld
A senior care home nurse failed to understand basic questions during a 999 call about a resident dying from sepsis, watchdogs have found.
The Local Government and Social Care Ombudsman said the nurse was asked if there was an immediate threat to his life, but said she didn't know. The ombudsman upheld the complaint against Bristol City Council by the man's son. Sepsis training has now been introduced at the care home in Westbury-on-Trym. It also found the council had failed to adequately record the findings of a safeguarding inquiry into the man's care at Hazelwood Gardens nursing home, but it ruled no significant injustice was suffered. The man's son complained to the ombudsman that his father was caused distress in his final hours which he believed contributed to his death. He said the council's inquiry report was "inadequate, lacked accuracy and trivialised events". The watchdog said the nurse phoned the emergency services at 05:30 on 24 February, 2019. When the ambulance hadn't arrived within the hour as promised, the nurse called 999 again and said it was possibly life-threatening, and paramedics arrived 23 minutes later. They took the man to Southmead Hospital but he did not regain consciousness and died eight days later on 4 March. 'Struggled to understand' The ombudsman's report said the council received a safeguarding referral from South Western Ambulance Service over the nurse "not recognising possible sepsis". "The nursing home accepted the nurse did not follow guidelines," the ombudsman said in the report. "The nurse could not say what level of threat there was. She also struggled to understand basic questions. "I have found fault in some aspects of the council's initial enquiry. It failed to adequately plan the investigation or maintain oversight. It also failed to properly record the outcome. "It has identified areas where the nursing home got things wrong and it was satisfied with the actions put in place to prevent similar issues happening again," it added.