Mum died of sepsis after 'GP diagnosed ear infection and sent her home with a spray'

A mum-of-three died of sepsis after she was diagnosed by a GP as having an ear infection and sent home with a topical spray to treat it, an inquest heard.

Two days later, having called an ambulance, a medic failed to notice a blue tinge on Charlotte Alderson's lips and said she didn't need to go to hospital as her symptoms were 'generally within normal range'. The swimming instructor, from Suffolk, collapsed an hour later and despite the efforts of paramedics died at her home.

Her inquest heard she had suffered from multi-organ failure due to septic shock, due to the bacterial infection Strep A. Now, Darren Stewart - area coroner for Suffolk - has called for the 'expeditious development' of measures which assist medics in the early identification and treatment of sepsis.

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The inquest was told that Mrs Alderson first reported feeling unwell on December 17, 2022. Some two days later, she visited her GP surgery, but medical professionals observed that her symptoms were 'within normal range'.

A clinical scoring system, called Centor, to test for Strep A was used but this indicated that no antibiotics were required. Mrs Alderson was diagnosed with an outer ear infection and was given a prescription for a topical antibiotic spray.

The swimming instructor 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 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'. The coroner 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.

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.