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Sepsis following chemotherapy

01 November 2003

Mrs G, a 45 year old mother, was diagnosed as suffering from breast cancer. She underwent surgical treatment and a course of radiotherapy. She remained well for seven years, and then unfortunately developed metastatic recurrence of her disease.

Mrs G started a course of chemotherapy after having a Hickman line inserted. A letter was sent to her GP, advising of the risk of neutropenia, and the need to arrange an urgent FBC or referral to hospital in the event of symptoms or signs of infection.

The hospital where the chemotherapy was given had an open-admissions policy for patients receiving chemotherapy. This allowed direct admission, without the need for a GP referral, if patients were concerned about potential infection.

The weekend after her first course of chemotherapy, Mrs G became unwell. Her husband reported that she was feverish and very tired. Mrs G phoned the hospital, but was told to contact her own GP. She telephoned the out-of-hours service.

Dr L visited Mrs G and found her febrile, but didn’t feel that hospital admission was necessary. By the next evening, at midnight, Mrs G was sufficiently unwell to ask for another visit. She was seen by Dr W, who took scant notes, and diagnosed a rib fracture. Dr W didn’t record a temperature.

By 11 o’clock the next morning, Mrs G was worse, phoned the hospital again and was told to come in. Unfortunately, she was suffering from overwhelming sepsis secondary to neutropenia, and died shortly after admission.

A legal action was launched against Drs L and W, alleging a breach of duty of care for failing to refer Mrs G to hospital after assessment. The hospital was also named for failing to honour its clinical protocol by not admitting Mrs G when she first telephoned.

Expert opinion

GP experts criticised Dr L for failing to enquire about chemotherapy and, in the presence of a fever, for failing to arrange immediate hospitalisation. Dr W’s scanty assessment, without a temperature recording, was seen as ‘grossly inadequate’.

Oncological opinion was critical of the hospital for referring Mrs G back to her GP, when she’d telephoned to say she was unwell, noting that it was likely she would have survived her infection, had she been admitted to hospital at the appropriate time. However, it was accepted that her long-term outlook remained poor with an expected median survival of several months.

We settled the case for a moderate sum, with liability shared equally between the three parties.

Learning points

  • Chemotherapy - patients receiving chemotherapy are at risk of overwhelming sepsis which may evolve very rapidly. When assessing a febrile patient, it is important to establish whether there are any reasons why the patient might be immunocompromised, and refer them to hospital immediately, if this is the case. The doctors concerned may not have had the benefit of the letter advising about the risks of neutropenia, but the information would have been revealed by a fuller assessment.
  • On-call - when acting as an on-call or deputising doctor, it is important to take a full history when assessing a patient, as you may not know them or have their notes.
  • Following protocols - the protocol for direct hospital admission should have been followed, and may have prevented Mrs G’s early death. Staff should be made aware of any departmental protocols in force, and this is particularly true for new starters, trainees and temporary staff. Patients could also be given a copy of relevant information to give to any doctor.