Sepsis continues to be ‘urgent and persistent’ safety risk in the NHS, reports warn

Recognising the signs of sepsis continues to be an ‘urgent and persistent’ safety risk in the NHS, a series of reports have warned.

The Health Services Safety Investigations Body (HSSIB), an independent arm’s length body of the Department of Health and Social Care, found ongoing challenges in early diagnosis of the life-threatening emergency.

It highlighted the difficulty of diagnosing sepsis ‘in its early stages’ and pointed to specific cases showing ‘how quickly a person with sepsis can deteriorate’.

It follows the investigation of three cases where the HSSIB found that patients and family members are not always listened to when expressing concerns.

One of the examples highlighted was an elderly man called Ged who was usually cared for at home by his wife after having a stroke. After being admitted to a care home, he was diagnosed with a urine infection after a few days of appearing confused and an initial urine test coming back negative.

An out-of-hours GP had prescribed antibiotics but they had been sent to a local pharmacy rather than on the nursing home’s electronic system which the GP was not familiar with.

The antibiotics were delivered but because they weren’t on the electronic system, nursing staff in line with their policy did not give them to him until 8pm the following day.

He became more unwell that evening with an ambulance called in the early hours. Ged was diagnosed with sepsis and died later that day, the report said.

GPs at practice supporting the nursing home were not familiar with prescribing on the electronic patient record system it used, and the system was not used by GPs at the out-of-hours GP service, the investigation found.

A new process put in place after Ged’s death to manage out-of-hours prescriptions is not well understood by staff and ‘involves multiple steps and communications across teams which creates a risk of delays in care and treatment’, it added.

It also found that a GP practice, hospital clinicians and GP out-of-hours services all had responsibilities for patients at the nursing home which ‘created challenges’.

Other examples highlighted patients where the severity of their condition had not been recognised on admission to hospital, including Lorna who died after going to hospital with abdominal pain.

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, the HSSIB said.

The HSSIB said: ‘Despite extensive national work and awareness campaigns, the recognition of sepsis remains an urgent and persistent safety risk.

‘Although sepsis has been the focus of extensive national work, it has persisted as a safety risk. The themes from incidents and complaints have remained the same over time.

‘Evidence from the intelligence gathered suggests that greater insight into the challenges faced at an organisational level in recognising sepsis would be helpful.’

Melanie Ottewill, senior safety investigator at HSSIB, said the reports showed a ‘consistent pattern of issues around the early recognition and treatment of sepsis’ and should be shared widely among NHS organisations.

She added: ‘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.’

The HSSIB also recently found that hospitals’ failures to send patient information to GPs have led to patient harm.