The ongoing crisis in the NHS is well documented, with problems in Emergency Departments, in
particular, garnering headlines. A recent BBC report into the death in April 2023 of a 56-year-
old woman who died of sepsis at the Queen Elizabeth Hospital, Birmingham, has illustrated
perfectly how a perfect storm of long waiting times and staff shortages in the Emergency
Department were held to have contributed to what was probably an unnecessary death. This is
a situation that brought untold distress to the woman’s family.

The inquest into this patient’s death found that although it was from natural causes, the
Coroner Louise Hunt ruled that neglect was a contributory factor and that she intended to write
to the Department of Health and Social Care to inform them of the fact that an overwhelmed
Emergency Department was a significant contributing factor in the death.

Procedures Not Followed

The patient in question attended A&E but had to wait five hours before any routine repeat
observations were taken. These should have included blood pressure readings. The Coroner
found that a nurse had given the excuse that she was unable to take the patient’s blood
pressure due to the patient not keeping still. However, the Coroner dismissed this.

The Coroner said that because no observations were repeated for five hours it was clear that
overcrowding in the ED at the time was a significant factor in the failure to give the patient the
timely and appropriate care required. This contributed to a delay in diagnosis and treatment. If
sepsis had been suspected from the beginning, as the Coroner believes should have been the
case, the patient would have likely been treated with antibiotics.

The Coroner also expressed concern about what she called a ‘genuine lack of understanding
about sepsis’ and the fact that, in this case, it was not considered by anybody until after the
death of the patient.

Report Confirms Coroner’s Findings

The local NHS Trust produced a report into the patient’s death, which confirmed that
incomplete observations were the result of reduced staffing against the volume of patients. In
other words, long waits and overcrowding in the ED meant that staff were not able to do their
job properly. Repeated observations may have led to earlier identification of the deterioration
of the patient’s condition. If sepsis had been considered sooner, this may have meant that
antibiotic treatment could have started sooner.

It was admitted the failure to observe the patient’s blood pressure was a serious failure and
that she should have been seen sooner by the nurse in charge.

Why Does This Happen?

The Royal College of Emergency Medicine has already produced reports flagging up the crisis
surrounding long A&E waiting times and the harm done to patients including the increasing of
associated excess deaths. In the past year, more than 1.5 million patients have waited for 12
hours or more to be seen in the Emergency Department. While the causes are multifactorial
they include the lack of beds to admit patients from the Emergency Department, so called exit
block, together with some shortages in all types of staff.

As the case of this patient shows however there appears to be a real problem. The
consideration and diagnosis of sepsis has led to an estimated 245,000 cases and 48,000 deaths
annually in the UK according to figures reported by the UK Sepsis Trust and taken from a report
in the Lancet Journal of Respiratory Medicine.

Sepsis is also connected with life-changing complications in patients who survive including
physical, psychological and cognitive impairments. These patients also have a higher risk of
being readmitted to hospital after the initial diagnosis and treatment.

While the Emergency Departments have t olook at their processes it is also incumbent on Trusts
to manage all fo their workload so that the Emergency Department does not get overwhelmed
with patients waiting for admission.