Sam Morrish - 3 yo Boy
Sam - a healthy 3-year-old boy. After being ill for around a week (flu symptoms, stomach pain, and vomited) visited first general practitioner (GP) and was sent home with antibiotics. Next day, feeling worse, Sam sees second GP, sent home with cough medicine.
Initial Assessment

What do you think is going on with this patient?
(everyone to answer)

Initial Assessment ( ~3 min)

Within an hour of returning home, Sam not feeling well, pale, incredibly thirsty, no urine, dark vomit. Mom called NHS Direct and was told to take Sam to local hospital. While waiting in the queue, a passing staff member noticed Sam was critically ill, placed on O2, sent via ambulance to larger hospital.
Big Hospital
Big Hospital

Share what you are most concerned about.
(everyone to answer)

Assessment Review (~5 min)
Sam arrives larger hospital at 10:30pm. Diagnosed with pneumonia, prescribed antibiotics, concerns of possible sepsis, transferred to pediatric unit.

Pediatric unit, antibiotics administered at 1:30am. Sam continues to deteriorate.
Sam's Story

Sam died December 23, 2010 from sepsis, 12 hours after seeing second GP.
GP 1 - Diagnosed with flu and sent home with antibiotics
GP 2 - Diagnosed with flu, sent home with cough medicine
Local Hospital - Deteriorating while waiting in queue, placed on O2 and sent to large hospital
Large Hospital - Dx pneumonia, possible sepsis, prescribed antibiotics, transferred to pediatric unit, antibiotics given 3 hrs later, Sam dies 4 hours later.
Team Debrief
What can our team learn from this case to improve the care in a similar situation?
Clinical & Team Discussion (~5 min)
Systems Discussion
What systems do we have in place to prevent this?
(every team member to answer)
What system issues might have contributed to this outcome?
(every team member to answer)
Systems Discussion (~5 min)
- recognition of sepsis
- premature closure / confirmation bias - flu
- patient care coordination
- handoff communication
- care transitions
- delay in treatment due to poor outpatient triage
- delay in antibiotic administration
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