Reports highlight challenges in sepsis diagnosis

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. 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 GPs, 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.