Prevention of Future Deaths report secured after death of grandfather due to hospital’s failure to diagnose infection.

John was taken to Royal Stoke University Hospital after sustaining a cut on his foot that had become infected. Sepsis was initially suspected, he was placed on the ‘Sepsis 6’ pathway, and he was prescribed broad-spectrum antibiotics. The medical team concluded that John was delirious and that this was likely due to an infection.

The medical team initially considered a diagnosis of necrotising fasciitis (a very serious and fast acting tissue infection) but felt that to be unlikely as his LRINEC score was one. The LRINEC score is a tool used to support the early diagnosis of necrotising fasciitis. Its aim is to help distinguish necrotising fasciitis from other severe but non-necrotising soft tissue infections, such as cellulitis or an abscess.

It was later revealed that his LRINEC score had been calculated incorrectly and should have been five instead. Because of this, necrotising fasciitis was excluded, and the treating team were falsely reassured about his condition. An MRI scan was requested, however, because the medical team no longer suspected necrotising fasciitis this was not treated as urgent and was not prioritised for the same day.

The following day John was transferred to the Acute Medical Unit. Whilst there, he was not reviewed by the orthopaedic team, and he did not receive three doses of antibiotics, despite these being prescribed.

It was not until two days later that the MRI was chased up as it had not been undertaken. By this point, John was too ill to undergo the MRI and medical staff noted that he might be suffering from acute severe invasive tissue infection. He was taken to the operating theatre for a below the knee amputation, to remove the infected limb.

Unfortunately, despite the amputation surgery, John continued to deteriorate when transferred to the Intensive Treatment Unit. Sadly he then passed away overnight.