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Wednesday, 18 April 2018

Inspectors forced to intervene to help patient with suspected sepsis, report reveals

Written by Sally Wardle

Health inspectors were forced to intervene to help a patient with suspected sepsis at a hospital which was ordered to improve, a report has revealed.

Staff in the emergency department of Russells Hall Hospital in Dudley, West Midlands, failed to properly monitor and treat the patient after they were admitted, according to a Care Quality Commission (CQC) report.

The CQC said it was concerned by a lack of safety and leadership in the unit and rated its services as "inadequate".

The Dudley Group NHS Foundation Trust, which operates the hospital, was given an overall rating of "requires improvement".

The CQC report said: "In one case, the inspection team had to intervene to ensure a patient was reviewed and attended to as a matter of urgency.

"This patient in particular was admitted early in the morning and placed on the sepsis pathway, but did not receive antibiotics until two hours later and did not receive timely observations.

"The trust are currently undertaking a serious incident review into this case."

Senior clinicians deliberately left blood oxygen saturation readings off a national scoring system used to quickly identify acutely ill patients, inspectors were told.

When these findings were highlighted to the trust, one consultant said "it would trigger too many medical emergency calls" if they were included, the report said.

While senior leaders in the department used overcrowding as a reason for the "significant lapses in care", inspectors said on a number of occasions it was overstaffed and had a lower than average number of patients.

Professor Ted Baker, chief inspector of hospitals, said: "Patients attending the emergency department did not always receive robust and sufficient assessment of their clinical presentation and condition.

"This posed a significant risk that life-threatening conditions would not be identified and treated as quickly as they should have been.

"The culture within the emergency department was not open and senior staff did not recognise significant areas of risk and potential harm to patients.

"Governance systems were not robust and did not ensure safe and effective care was being delivered."

The trust, which was inspected between December and January, received a "good" rating overall for care provided by staff.

It was deemed to "require improvement" in whether the services were safe, effective, responsive and well-led overall.

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