Blackpool coroner: There remains a risk that sepsis will go unrecognised, and urgent treatment delayed

Sandra Phillpott, 57, of The Glades, Lytham, had felt unwell with cold-like symptoms after returning from a holiday with her twin sister on Friday, October 27 last year.

She had picked up an infection in Egypt and was taken to Blackpool Victoria Hospital by ambulance on Monday, October 30 after her condition worsened.

At first, doctors treated her for a suspected pulmonary embolism but later it was realised she was suffering from sepsis and she died the following morning.

Now, following an inquest into her death which found she died from natural causes including organ failure, the Blackpool and Fylde coroner Alan Wilson has written to hospital chiefs expressing concerns over delays in treating Ms Phillpott for sepsis.

Despite ruling quicker treatment would not have saved her life, Mr Wilson says he wants to raise concerns around "the recognition of suspected sepsis, and the need for timely provision of treatment for suspected sepsis".

He has issued a prevention of future deaths report following the inquest into her death which was held on July 5 this year.

His report describes Ms Phillpott, who worked as a contact centre manager for the ambulance service, "as active and previously healthy", and someone who had "preferred not to seek medical attention, expecting her symptoms to improve" over the weekend after arriving home.

But she attended a walk-in centre on Monday, October 30 when she continued to feel ill and was sent to A&E by ambulance. There she had a 40-minute wait in the ambulance before being seen.

The coroner's report says: "Initial investigations suggested she had a suspected pulmonary embolism, but she was also showing signs of infection and by 12 noon antibiotics and intravenous fluids had been prescribed.

"These were not administered in a timely fashion. Her presentation had not indicated she had a specific pneumococcal infection until later that afternoon when following a delayed transfer to the intensive treatment unit, a consultant noted a florid rash indicative of pneumococcal sepsis."

Blood tests confirmed sepsis and her condition deteriorated until she died at 5.50am on Tuesday, October 31, 2023.

The report adds: "The likelihood Sandra had sepsis had been under appreciated, and there was a missed opportunity to provide timely antibiotic therapy and fluids."

However, the coroner says evidence shows "this would not have altered the fatal outcome because from around the time antibiotics were prescribed Sandra’s condition was non-survivable".

He added: "She died from complications arising from a pneumococcal infection. She had been more susceptible to dying from such infection due to the effects of heart disease identified at post-mortem examination, and reduced physiological reserves caused by the separate infection which had been contracted in Egypt."

A patient safety incident investigation (PSII) report, provided to the inquest by Blackpool Teaching Hospitals NHS Foundation Trust, found doctors had delayed treating sepsis because initial treatment had focused upon ruling out a pulmonary embolism and deep vein thrombosis.

Mr Wilson said he wanted to raise concerns relating to the recognition of suspected sepsis, and the need for timely provision of treatment.

He says in the report: "Notwithstanding that I determined that from the available evidence, timely treatment would not have altered the fatal outcome, I remain firmly of the view this report is necessary.

"I was informed at the inquest that there have been significant improvements in the management of sepsis within the emergency department.

"This court has raised concerns with the hospital trust about this issue previously, and I know it is an issue which the trust is very aware of and I do not doubt that efforts have been made to make improvements.

"But having conducted this inquest into Sandra’s death, in my view there remains a risk that sepsis will go unrecognised, and urgent treatment will be delayed, putting patients attending Blackpool Victoria Hospital at risk."

Blackpool Teaching Hospitals NHS Foundation Trust must respond to the coroner by September 13.