Despite extensive national work and awareness campaigns, the recognition of sepsis remains an urgent and persistent safety risk, according to three reports published by HSSIB today.
The reports also highlight that family members are not always listened to when expressing concerns about a loved one’s condition deteriorating. Each report examined individual cases of sepsis relating to different conditions – in one a patient with diabetes and a foot infection, in another a patient with severe abdominal pain and in the third report an older patient with a urine infection.
The investigations were carried out in a different way to HSSIB’s usual approach. They are modelling patient safety incident investigations under the NHS Patient Safety Incident Response Framework (PSIRF) to boost local learning and help improve investigation quality.
The patient’s experience is analysed in depth in each report, with input from the healthcare providers (this spans GP’s, hospitals – wards and emergency departments - ambulance services and nursing homes), individual healthcare staff, one of the patients and family members of all the patients.
- Lorna arrived at an emergency department with severe abdominal pain and a fast heart rate. She was admitted to the acute assessment unit in the hospital. She was monitored by staff and various tests were undertaken and treatments given, but she continued to become unwell. When a doctor saw her in person, they recognised the signs of sepsis and antibiotics were given. Sadly, Lorna’s condition continued to worsen, and she died two days after her admission to hospital.
- Barbara was admitted to a hospital (Hospital A in the report) on 7 June with a severe infection in her right foot. She was referred to a specialist hospital (Hospital B in the report) because of the poor blood supply to her foot and potential need for vascular surgery. Antibiotics were started but over the course of 3 days Barbara’s foot infection did not improve and there were signs she was becoming more unwell. Barbara was eventually transferred to Hospital B on 11 June. On 12 June, she was found unresponsive and was diagnosed with sepsis. Barbara had to undergo a below the knee amputation to gain control of the infection. She had a complex recovery following the operation, only being discharged in the October.
- Ged had suffered a stroke and as result needed help with everyday living which was provided by home carers and his wife. When Ged’s wife went into hospital, Ged had to go into a care home to ensure his care needs were met. Whilst at the home he was diagnosed with a urine infection. Due to issues with communication and medicine systems Ged was not given his prescribed antibiotics in a timely manner. When Ged was admitted to hospital with sepsis, he was very unwell and sadly died that same day.
Whilst the reports are about different events, there were some common findings in relation to the recognition of sepsis.
- The reports reiterate the difficulty of diagnosing sepsis in its early stages and show how quickly person with sepsis can deteriorate. Barbara’s experience highlights the importance of ensuring that people receive specialist care and treatment quickly. Barbara was at high risk of sepsis because of her diabetes and poor blood supply to her foot.
- All three reports demonstrate the importance of listening to a family’s concerns about their loved ones – this was particularly apparent in Lorna and Ged’s experiences. Lorna’s family told the HSSIB they didn’t feel heard or listened to despite repeatedly raising their concerns about how unwell she was.
- Two of the three reports emphasise the importance of confusion as a sign that a person’s health is deteriorating and the importance of involving family members in assessing changes in a patient’s mental state.
All reports highlight areas for improvement that support the early recognition and treatment of sepsis. Although the areas of improvement were directed at the individual organisations involved in the patient safety incidents, the findings and recommended improvements offer valuable insights for all healthcare organisations and staff. These insights can help improve the identification and definition of sepsis when reporting patient safety events and investigating incidents where sepsis is suspected.
Melanie Ottewill, Senior Safety Investigator, said: “These reports provide examples of patient safety incident investigations under the Patient Safety Incident Response Framework (PSIRF). However, they also show a consistent pattern of issues around the early recognition and treatment of sepsis.
“The experiences of Barbara, Ged and Lorna show the devastating consequences of sepsis. They also highlight the imperative of listening to families when they express concerns about their loved one and tell us about changes in how they are. The distress caused by not feeling heard significantly compounded the grief of Ged’s and Lorna’s family. The trauma of their loss was deeply felt throughout their involvement in our investigation.
“These findings must be shared widely across NHS Trusts — both for the valuable learning around sepsis and as a model for patient safety incident investigations under PSIRF. Each report contains detailed analysis and practical insights, offering a significant body of learning for improving patient safety and conducting effective investigations.”
Dr Ron Daniels, Founder and Chief Medical Officer, the UK Sepsis Trust, says: “These reports provide a valuable reiteration of how quickly sepsis can develop (and therefore how swift diagnosis and treatment must be), as well as a reminder of why it’s so important to maintain consistent awareness of every sepsis symptom. It’s critical too that members of the public feel empowered to act as advocates when their loved ones are unwell, and that healthcare professionals take them seriously.
“We also need a commitment from health ministers on the development and implementation of a ‘sepsis pathway’ - a standardised treatment plan that ensures patients receive the right care from the point at which they present their symptoms to a clinician through to receiving their diagnosis. By responding effectively and reliably to sepsis, our health service can save lives and improve outcomes for the thousands of people affected by this condition every year.
Download the report at Sepsis: investigating under the Patient Safety Incident Response Framework (PSIRF)
