Father of 2 Died from Sepsis After Waiting 34 Hours for Medication

A father of two died from sepsis after a hospital delay meant he did not receive the correct medication for 34 hours, according to a new investigation.

On Wednesday, Dec. 10, the Parliamentary and Health Service Ombudsman (PHSO) said a 45-year-old man might have survived if he had been given antibiotics sooner at Bassetlaw Hospital in Worksop, England, in November 2022.

The man, who had disabilities, was sent to the hospital by a primary care physician after developing a urinary infection. Although intravenous (IV) antibiotics were prescribed, the Ombudsman found he waited 34 hours before receiving them.

“The Parliamentary and Health Service Ombudsman (PHSO) found that his death was avoidable,” the statement said. The man lived in supported accommodation in Ollerton, Nottinghamshire, and had Alexander’s Disease — a rare, incurable condition that affects the nervous system.

He also had respiratory and mobility issues, required 24-hour care, and needed assistance with feeding and personal hygiene. Because he had a permanent catheter, he was considered vulnerable to recurrent urinary tract infections (UTIs), the Ombudsman said.

The investigation also noted communication challenges: the man struggled to express his needs to medical staff. His mother raised concerns while he was in hospital but did not realize the IV antibiotics had not yet been administered.

Hospital staff were told by paramedics and care home workers that the patient required IV antibiotics. However, while the primary care physician had uploaded test results into an online system, the hospital reportedly did not use them because the request was not provided in writing.

Instead, following consultation with a microbiologist, staff attempted to use an oral antibiotic — but the specific drug requested was not available. The Ombudsman concluded clinicians should have sought further advice at that point, and that doing so would likely have led to IV antibiotics being recommended and available.

When the IV antibiotic was eventually given, it was administered “34 hours after he arrived at [the] hospital, and at half the dosage it should have been,” the Ombudsman said. The investigation also found an additional three-hour delay between doctors requesting the medication and it being given.

By the time a second dose was administered, the man had become septic. He died a week later.

“In this case, a man who was unable to advocate [for] himself and completely reliant on clinicians to look after him did not receive the care he needed. Tragically, this meant he unnecessarily lost his life,” Rebecca Hilsenrath KC (Hon), the Ombudsman’s chief executive, said.

She added that deaths from sepsis “should not be an inevitability,” and said the office has seen recurring failures, with complaints involving sepsis more than doubling over the past five years. She also pointed to persistent issues in communication between patients and clinicians and urged accountability, openness and learning across the NHS.

The man’s mother said she tried to warn doctors that an oral antibiotic would not work and that the GP had a microbiologist’s report indicating her son would not respond to that drug.

“But they just totally dismissed me. Their attitude was they were the doctors, and I was just his mum,” she said.

“It was heartbreaking to finally understand the truth,” she added, saying she believed her son had been given at least some antibiotics. “But to find out he was in hospital for all that time with no treatment was very hard.”

In a statement, the Doncaster and Bassetlaw Teaching Hospitals NHS Foundation Trust said it was “truly sorry” for what happened and for the family’s loss. The trust said it reviewed the care through its Patient Safety Panel and implemented immediate actions to strengthen how antibiotics are prescribed, escalated and administered.