It sounds far fetched, but it happened – a Lennox woman went into the hospital with a broken ankle and ended up dying a few weeks later.
The cause – something you may never even have heard of – Sepsis. It can happen from any infection and if not caught early, it is deadly.
It’s also on the rise in the United States, with more than one million cases a year. And it’s one of the top ten patient safety issues for 2016.
Norma Reiners wasn’t your typical 85-year-old. She still lived in her own home and walked two miles a day on the treadmill and didn’t take any medication.
“She didn’t look 85; she didn’t act 85,” Brenda Ludens, Norma’s daughter, said.
Yet one night, she got up and fell down the stairs and broke her ankle.
“I thought, we’ll put a cast on, I’ll take her home with me, not a big deal,” Ludens said.
It turned out to be a little more complicated than that. Norma’s ankle wasn’t a candidate for a cast, so doctors put her in an external device to set the bones until she could have surgery at a later date. She went to a skilled nursing home because she needed help with that bulky device on her ankle.
A few weeks later she was supposed to get a cast on and go home. But instead, she became ill over a weekend.
“I said to the nurse, you know, she’s not herself. Her condition is deteriorating, she’s changing, This is not her. This is not my mother,” Ludens said.
Ludens was told to hold off until her mother saw the orthopedist on Monday.
“There was drainage from the pin sites of the fixator. She had a temperature, she had an increased heart rate. He thought there might be an infection in the leg, so he prescribed an oral antibiotic. And said we were free to go back to the skilled nursing facility,” Ludens said.
Ludens, who is a respiratory therapist, wasn’t so sure.
“I said, ‘What should we do about her present condition? Look at her. What should we do about that now?’ He said, ‘Well I think it’s just the flu,'” Ludens said.
Ludens said she was relieved to hear that it was just the flu and her mother went back to the nursing home. But Ludens got a call 10 hours later to come and take her mother to the emergency room.
“Great! She’s going to the ER. This is what I said should have been done at 8 o’clock this morning. It’s finally happening,” Ludens said.
Only Ludens wasn’t prepared for how quickly her mother had gone downhill.
ER doctors told her Norma had had a heart attack and a urinary tract infection. Over the next 48 hours she didn’t respond to treatment.
“We couldn’t believe it was happening. We couldn’t believe it was happening. But it did,” Ludens said. “At 11:30 that evening, she passed away.”
It wasn’t until Ludens got her mother’s death certificate that she learned the cause of her death was Sepsis, which is a blood stream infection that causes the organs of the body to shut down and if not treated, leads to death.
“I never heard the word Sepsis, or the fact that Sepsis could be a possibility. It was never mentioned during her care,” Ludens said.
Ludens took it upon herself to learn everything she could about Sepsis and concluded that her mother had shown the signs and symptoms four days before being admitted. The longer Sepsis goes untreated, the higher the likelihood of death.
“She didn’t have the flu. She had Sepsis. And she died from Sepsis. In my opinion, a perfectly preventable death,” Ludens said. “It was a clear case and a perfect example of what could go wrong, did.”
Ludens took her mother’s case before Sanford Health’s administration. Sanford Health is also her employer.
“I wanted to use this story to affect change. Their approach to my concerns, in my opinion, were more deny and defend,” Ludens said.
She also reported it to the Joint Commission which accredits healthcare organizations; after hearing from Sanford, the Joint Commission said the hospital’s response was acceptable.
Ludens also went back to the Good Samaritan nursing home where her mother had been staying to ask for more training of staff on the signs of sepsis. Both Sanford Health and Good Samaritan declined to be interviewed for this story. Sanford issued us a statement saying privacy laws prevent it from commenting on a specific patient.
But then, shortly before this story was to air, Sanford sent us a a revised statement saying it fully supported Ludens’ desire to raise awareness about the symptoms and early detection of Sepsis.
In a letter to Ludens provided to KELOLAND News, Sanford told Ludens her mother’s orthopedic treatment met the standard of care, and Sanford has launched a Sepsis Initiative for early detection. Sanford tells KELOLAND News is started that initiative four months before Luden’s death.
“The medical community let me down. And in an even larger part, I blame myself because I should have known more, I should have done better. I should have been a better patient advocate,” Ludens said.
Ludens, a respiratory therapist, has now joined the patient safety movement. She attended the national conference in January and hopes to share her mother’s story as much as possible to raise awareness about preventable deaths.
“So if this can happen to me and my family, it can happen to any family. And that’s my goal, to educate; Make people aware of the signs and symptoms of Sepsis,” Ludens said.