Mother of Three Dies from Sepsis After Misdiagnosis by GP and Missed Symptoms by Medic

A coroner has called for a review of the methods used to identify sepsis following the death of a mother who was diagnosed with an ear infection and sent home with a topical spray to treat it.

Charlotte Alderson, 34, collapsed two days after visiting her GP but an emergency medical technician 'did not observe' a blue tinge on the swimming instructor's lips and concluded she did not need to go to hospital.

An inquest heard she had suffered from multi-organ failure due to septic shock. The results of a throat swab which returned after Mrs Alderson's death confirmed the presence of Strep A bacteria, which led to her developing sepsis.

Coroner Darren Stewart has now called for the 'expeditious development' of measures which assist medics in the early identification and treatment of sepsis.

Sepsis is known as the 'silent killer' and develops when an infection causes a severe immune response, with the body attacking its own organs.

The Daily Mail has been campaigning to raise awareness and improve sepsis care since 2016.

An inquest earlier this year was told Mrs Alderson, a mother-of-three, first reported feeling unwell on December 17, 2022.

Some two days later, she visited her GP surgery and her doctor took the throat swab to see if antibiotics were needed. Her symptoms were said to be 'within normal range'.

Mother-of-three Charlotte Alder, 34, collapsed and died at home, an inquest heard

A clinical scoring system, called Centor, to test for Strep A was used but this indicated that no antibiotics were required.

Mrs Alderson, from Beck Row, Suffolk, was diagnosed with an outer ear infection and was given a prescription for a topical antibiotic spray.

She was told to return to her GP if her symptoms worsened.

On December 20, Mrs Alderson reported feeling better, but then in the evening her condition deteriorated and she suffered bouts of sickness and diarrhoea throughout the night.

The following morning, at around 11am, her husband Stuart Alderson checked on her and observed a 'blue tinge' on her lips.

He called 111 and an ambulance was dispatched.

While the service was en-route, Mrs Alderson's symptoms again worsened, which prompted Mr Alderson to make an additional call to 999.

The ambulance arrived at 11:57am and a senior emergency medical technician (EMT) carried out a clinical assessment on Mrs Alderson.

The responder did not see blue-tinged lips and found that apart from a 'slightly elevated' temperature and heart rate, observations were 'generally within normal range'.

At the scene, the Senior EMT called Mrs Alderson’s GP surgery and discussed symptoms and observations with the duty doctor, which the inquest heard was standard practice at the time.

But Dr Emma Ayers, the duty doctor, told the inquest that due to a receptionist’s note she believed Ms Burt was a paramedic, a higher rank than an EMT, and that, had she known, she may have challenged a decision not to take Mrs Alderson to hospital.

Mr Stewart, area coroner for Suffolk, said: 'With no requirement identified for immediate hospitalisation, the ambulance left at 13:15.'

'Mrs Alderson's conditioned worsened further and her husband left to purchase pain relief.

Upon his return, he found Mrs Alderson in a state of collapse. She was unconscious but breathing.'

Mr Alderson immediately called 999 at 14:09 and during this call, his wife had stopped breathing.

An ambulance arrived at 14:26 and despite attempts to resuscitate Mrs Alderson, the swimming instructor sadly passed away at home.

A post-mortem examination carried out after her death revealed she had group A streptococcus, a common type of bacteria infection.

A jury inquest concluded Mrs Alderson died of natural causes.

The medical cause of death was multi-organ failure due to septic shock, arising from the rapid progression of a bacterial infection into the bloodstream.

Mr Stewart said he has several 'matters of concern' regarding the circumstances of Mrs Alderson's death.

He said there are two scoring systems - Feverpain and Centor - used by clinicians to assess infections in patients and these can produce different outcomes.

The coroner said: 'It is possible in Mrs Alderson's case that the use of the Feverpain scoring system (as opposed to Centor) may have made a difference by indicating a prescription for antibiotics, which if taken on the day she was assessed by her GP, may have resulted in a different outcome.

There is a need to review these scoring systems, drawing upon the most effective elements of each, with a view to providing guidance on a single scoring system that can consistently be applied by clinicians.'

He continued: 'Evidence received during the Inquest indicated that a number of existing measures within the National Health Service are capable of modification to provide testing tools for the early identification of sepsis/risk of sepsis and which would better inform decisions to prescribe antibiotics.

These include CRP, finger prick and lateral flow tests.

The risks associated with sepsis and the speed with which a rapid deterioration can occur in patients without clear warning signs of sepsis being present, are well known.

There is therefore a need for the expeditious development of measures which assist clinicians in the early identification and treatment of sepsis.'

The coroner also raised concerns about the system used by 111 call handlers.

This was after hearing of how it can fail on occasion and mean that ambulances need to be booked manually over the phone rather than automatically.