Necrotising Fasciitis & Sepsis Breach Nursing Expert Witness Case Study

In the forensic environment of clinical negligence litigation, the timeline of a deteriorating patient is often viewed through the lens of a "missed opportunity." For necrotising fasciitis, a rapidly progressive, life-threatening "flesh-eating" bacterial infection - the window for intervention is measured in minutes, not days. In this arena, "time is tissue," and the adequacy of early-stage nursing assessment is frequently the pivot point upon which a claim for liability turns.

At Apex Experts, our panel is regularly instructed to evaluate cases where the early signs of soft tissue infection were subtle, yet the physiological "red flags" were present. This case study examines a patient admitted via community referral with an exquisitely painful, swollen arm, and explores how a failure in initial sepsis screening led to a significant breach of duty.

The Anatomy of the Claim: Subtle Signs and Severe Pain

The matter concerns a patient who presented to the Emergency Department with a painful, swollen upper limb. On initial presentation, the clinical markers were non-specific but concerning. The patient exhibited:

• A solitary, small blister on the elbow.

• Disproportionate pain, described as severe and unrelieved by oral codeine.

• Mild pyrexia (fever).

• Tachycardia (elevated heart rate) and an increased respiratory rate.

• No clear history of penetrating trauma or injury.

While the diagnosis of necrotising fasciitis is notoriously difficult in its infancy (often mimicking simple cellulitis) the nursing expert’s role is not to diagnose, but to recognise and rescue. The central question in this claim was whether the nursing staff adhered to the established sepsis protocols that are designed to catch life-threatening infections before they become catastrophic.

The Nursing Expert Witness Review: Identifying the Breach in Sepsis Protocol

An Apex nursing expert witness was instructed to review the triage notes, observation charts, and the hospital’s internal sepsis screening proforma. While the subsequent surgical and intensive care was deemed of a high standard, the expert identified a critical failure during the first two hours of the patient’s journey.

1. Inaccurate Screening and "Failure to Flag"

A sepsis screening proforma had been completed at triage, but the expert noted it was completed inaccurately. Despite the patient exhibiting both a raised respiratory rate and tachycardia, the nurse failed to recognise these as "Red Flag" criteria. According to the UK Sepsis Trust guidelines and the National Early Warning Score (NEWS2) protocol, the presence of these physiological stressors in the context of a suspected infection should have triggered an immediate "Sepsis Six" pathway and a senior medical review.

2. The "Pain Out of Proportion" Red Flag

One of the hallmark signs of necrotising fasciitis is pain that is significantly more severe than the physical appearance of the skin would suggest. The expert noted that the patient’s pain was rated high enough to warrant opioid analgesia, yet this objective marker of deep-tissue distress did not prompt any escalation to the surgical registrar on call.

3. The "Low CRP" Trap

The defence argued that because the patient’s C-Reactive Protein (CRP) levels were initially low, the nursing staff were justified in their "wait and see" approach. However, the nursing expert was unequivocal: a low CRP in the very early hours of an infection does not rule out a surgical emergency. The nurse’s duty is to the clinical picture at the bedside - the tachycardia and the escalating pain - rather than a single laboratory result.

What a Nursing Expert Expects: The Standard of Care

In the eyes of the court, a "reasonable" nursing professional is expected to act as the patient's primary advocate and safety net. When evaluating early-stage infection care, our expert witnesses look for adherence to several key benchmarks:

• Full Protocol Compliance: When a patient presents with unexplained severe pain and a fever, sepsis screening is not optional; it must be performed with clinical precision.

• The Power of Escalation: If a screening tool flags two or more systemic inflammatory response markers, the standard of care requires the nurse to move up the chain of command.

• Prompt Antibiotic Administration: In cases of suspected sepsis, national standards dictate that the first dose of broad-spectrum antibiotics should be administered within the "Golden Hour." In this case, there was a multi-hour delay.

• Dynamic Reassessment: If the diagnosis remains uncertain, nursing staff are expected to conduct frequent (every 30 to 60 minutes) observations to track the trajectory of the patient’s physiological decline.

The Documentation Deficit

A significant factor that undermined the hospital’s defence was the quality of the record-keeping. The expert noted that several vital observation charts were missing time stamps, and many entries lacked a printed name or clear signature.

In British medico-legal practice, "if it isn't written down, it didn't happen." The lack of a clear, chronological narrative made it impossible for the Trust to prove that they had monitored the patient's deteriorating condition with the required frequency. For the solicitor, these documentation gaps serve as a "speculation vacuum" that often leans in favour of the claimant's version of events.

Conclusion: The "Junior Nurse" and Systemic Pressure

The expert’s conclusion was not one of malice or lack of care, but of a failure in clinical judgement at a critical juncture. While the surgical team ultimately performed life-saving surgery and the critical care nursing was exemplary, the initial breach during triage set in motion a delay that allowed the infection to spread significantly further into the soft tissue.

From a nursing standpoint, the breach was significant. While the expert deferred to medical colleagues (Vascular or Orthopaedic Surgeons) on the specific question of Causation - whether the delay caused the eventual tissue loss - the establishment of the Breach of Duty provided the solicitor with a solid foundation for the claim.

Lessons for the Medico-Legal Practitioner

For solicitors and insurers, this case illustrates that the strongest evidence in an NF claim is often found in the triage notes. It is the failure to connect the dots between heart rate, respiratory rate, and pain that creates liability.

At Apex Experts, we provide the clarity required to navigate these complex timelines. By focusing on the NMC Code and national sepsis standards, our experts move beyond the "tragedy" of the outcome to provide a logical, defensible analysis of the clinical process.