Recognition of sepsis ‘urgent and persistent safety risk’ – report

There are “ongoing challenges” in the early diagnosis of a life-threatening medical emergency, safety experts have said.

The Health Services Safety Investigations Body (HSSIB) said that the “recognition of sepsis remains an urgent and persistent safety risk”.

It comes as the watchdog examined three cases where patients suffered severe harm or death as a result of sepsis not being diagnosed soon enough.

Sepsis is a life-threatening reaction to an infection that occurs when the immune system overreacts and starts to damage the body’s tissues and organs.

In the UK, 245,000 people are affected by sepsis every year.

The three cases described in HSSIB’s latest reports include:

– An elderly man named as Ged, who had a urine infection. Ged died from sepsis after his antibiotics were not given to him for almost 20 hours due to difficulties lining up GP out-of-hours systems and those of his nursing home.

– A grandmother called Lorna, who died from sepsis after being admitted to an acute assessment unit after attending a hospital with abdominal pain. HSSIB said that doctors on the AAU “did not always have the capacity to review patients in person” and that it was only when she was seen by a doctor some hours later her sepsis was recognised.

– A woman named Barbara, who had diabetes and a foot infection, which led to sepsis. She survived her ordeal but needed to have her leg amputated below the knee to “gain control” of the infection. Concerns were raised that she should have been transferred to a second hospital sooner and whether this would have avoided her developing sepsis and the need for such extensive amputation. She spent four months in hospital.

HSSIB said that the reports also highlight how family members are not always listened to when expressing concerns about a loved one’s condition deteriorating.

It said the reports reiterate the difficulty of diagnosing sepsis in its early stages.

Melanie Ottewill, senior safety investigator at HSSIB, said: “These reports 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 families.

“The trauma of their loss was deeply felt throughout their involvement in our investigation.

“Each report contains detailed analysis and practical insights, offering a significant body of learning for improving patient safety and conducting effective investigations.”

Commenting on the reports, Dr Ron Daniels, founder of the UK Sepsis Trust, said: “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.”

An NHS England spokesperson said: “NHS staff work extremely hard to keep patients safe and NHS England has supported the implementation of Early Warning Systems to improve recognition and response for all causes of deterioration, including sepsis.

“The introduction of Martha’s Rule and the routine use of patient wellness questionnaires is also helping patients and their families to alert staff to subtle changes in how patients are feeling – potentially identifying early signs of deterioration – while giving them the right to call for an urgent review if they remain concerned about a patient getting worse.”

Published: 26/06/2025 by Radio NewsHub