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HDC Case - Recognition and treatment of sepsis

Source: Health and Disability Commissioner


Health and Disability Commissioner Anthony Hill today released a report finding a general practitioner (GP) and a District Health Board (DHB) in breach of the Code of Health and Disability Services Consumers’ Rights (the Code) for failing to appropriately recognise and treat a woman’s presentation of sepsis.

A woman in her seventies went to a medical centre with a leg wound. A nurse saw her first, noted low blood pressure, low temperature and confusion and asked the GP to review the woman. The GP considered the woman had an infection but was otherwise well. He prescribed antibiotics and told her to seek medical attention if her condition worsened. The GP did not take her blood pressure and did not realise it was low.

The woman attended the emergency department (ED) of the public hospital later that day, where there was a delay in her being seen. She was eventually diagnosed with septic shock and was admitted to the intensive care unit.

Mr Hill considered that the GP failed to give adequate consideration to those risk factors which indicated sepsis, including low blood pressure.

"As a consequence of these failures, the opportunity was missed to identify and access treatment for [the woman’s] sepsis at an earlier time," Mr Hill said.

Mr Hill was also critical of the DHB for not having appropriate systems for triage, resulting in the woman being triaged incorrectly and a delay in her receiving treatment. Mr Hill acknowledged the pressures of a busy ED but said, "[A] busy environment under pressure does not remove the obligation to provide appropriate services, and does not remove provider accountability for ensuring that appropriate steps are taken."

The full report for case 18HDC00793 is available on the HDC website  


Last updated : Tuesday, July 28, 2020

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