Shropshire hospital trust responds to coroner over sepsis delay concerns
The trust running Shropshire's two main hospitals says it has responded to a coroner over concerns relating to a delay in the treatment of a patient with sepsis.
Coroners can make reports to a person or organisation where they believe that action should be taken to prevent future deaths.
A report was issued to Shrewsbury and Telford Hospital NHS Trust (SaTH) relating to an inquest into the death of a patient following a delay in diagnosis of sepsis.
It outlined several concerns and asked what actions the trust has made to bring in improvements.
The trust board was told the news during a meeting on Thursday.
A report to the board said: "The trust was issued with a Regulation 28 Prevention of Future Death Report on the June 19.
"This related to an inquest into the death of a patient who died following a delay in diagnosis of sepsis.
"The coroner highlighted three points for the trust to respond to and explain what actions have been taken to improve this."
They were that too few doctors were on duty in general to cover patient needs and there did not seem to be a programme in place for trying to get a third doctor to cover sickness absence.
Concern was also raised that specific medication was not in stock and led to a delay in administration of two hours and 25 minutes.
Action
The coroner's report said whilst there was a general awareness of the dangers from sepsis, "red flags of sepsis were missed" and leg bandages were not removed to allow for a full top to toe examination.
Deirdre Fowler, director of nursing, midwifery and quality at SaTH, said the trust had responded to the notice.
The response from the trust will be published on the Ministry of Justice website in due course.
It comes as the Care Quality Commission took urgent enforcement action against SaTH following an inspection.
One of the conditions it imposed was around the systems SaTH has in place around patients who may present with sepsis or other deteriorating medical conditions in the emergency departments.
But the report put before SaTH's trust board said: "Since the visit the trust has enhanced the processes already in place to identify, escalate and manage patients who may present with sepsis or deteriorating condition.
"Monitoring has shown that there has been much improved compliance with both observation and escalation."
