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Sepsis: Lessons not being learned, warns ombudsman

Ten years after a landmark report into gaps in sepsis care in the NHS, a new one has been published – and suggests the same problems are still present.

The Parliamentary and Health Service Ombudsman, last week, published Spotlight on Sepsis: Your Stories, Your Rights, a new report which found that “too many lives” were still being claimed by sepsis due to failings in hospitals.

“It is clear that lessons are not being learned”

Rob Behrens

Ombudsman Rob Behrens called on NHS organisations to “embed learning cultures” in relation to sepsis, including being more transparent about mistakes.

He also asked that families affected by harm, due to poor sepsis treatment, are given more support.

Spotlight on Sepsis included several case studies, and demonstrated gaps in the knowledge and training of hospital staff in relation to sepsis.

Its publication comes shortly after a campaign was launched to give patients the right to a second opinion when they think clinicians have missed something in a deteriorating patient. This campaign, for Martha’s Rule, is led by the mother of a young girl who died of sepsis which was initially missed by clinical staff. 

Mr Behrens said some of the stories he had heard through his service’s investigations were “harrowing” and frustrating.

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He pointed to the 2013 Time To Act report, also published by the ombudsman, and said that the evidence suggested that in the 10 years since it was put together, there had not been enough done to address the key issues.

According to the 2023 report, there are around 48,000 sepsis fatalities in the UK each year out of around 245,000 total cases.

It said while “some improvements” had been made in the last decade, it was still seeing cases of people dying from sepsis because they “did not receive the right care at the right time”.

“It is disappointing to see that the issues we identified 10 years ago are still the same as we see in our casework today,” the report reads.

Spotlight on Sepsis referenced one case of a woman named Kath, who died at Blackpool Teaching Hospitals NHS Foundation Trust after her sepsis was not treated or spotted in time.

The woman was admitted to hospital with pneumonia in 2017, and developed further complications. She died around two weeks later after a fall and then a cardiac arrest.

The ombudsman’s investigation found that the woman had shown “clear signs” of sepsis, which should have been spotted and acted on.

“The ombudsman said there was a missed opportunity to identify and treat sepsis which would have likely prevented Kath’s deterioration, and death,” the report said.

Another case quoted in the report was that of a man identified as Mr O, who died at Tameside and Glossop Integrated Care NHS Foundation Trust in January 2018, around two months after initial contact with the hospital.

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The man had dementia and other pre-existing medical conditions, and was admitted after collapsing one day.

He was discharged, but readmitted a week later with a temperature and sleepiness; Mr O was treated for a urinary tract infection and possible sepsis.

He was moved to a ward and during his hospital stay he developed a moisture lesion at the base of his spine and a grade 2 pressure ulcer. He was given barrier cream, fluids and antibiotics.

“We are also gravely concerned that attention to sepsis is being afforded lower priority in the wake of the pandemic”

Ron Daniels

After Mr O’s condition worsened on 21 January, hospital staff determined that active treatment should be stopped and there was nothing more that could be done for him.

He died at a hospice a few days later. There, staff spotted a grade 4 lesion with moisture damage – the lack of treatment of which, the ombudsman determined, led to his sepsis and death.

In this case, the ombudsman said the trust had failed to assess the man’s risk of developing a pressure ulcer, failed to put him on an individualised care plan, and that there were overall poor levels of documentation around his case.

The report said that Mr O had not been referred to tissue viability nurses at the proper time, which led to his skin integrity getting worse, in turn causing his sepsis.

These issues, Mr Behrens said, were similar to what was found in the 2013 report.

“It frustrates and saddens me that the same mistakes we highlighted 10 years ago are still occurring,” he said.

“It is clear that lessons are not being learned.”

Rob Behrens

Rob Behrens

He said complaints from patients, like those received by the ombudsman, had the “power to reveal the truth, bring closure and create lasting positive change”.

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“But complaints must be handled properly, and findings acted upon. Losing a life through sepsis should not be an inevitability,” added Mr Behrens.

“The NHS needs to listen to patients and their families when they raise concerns. It needs to be sepsis-aware.

“We know early detection and treatment is crucial. It is time to make sure complaints count, and patients’ voices are used to shape action on sepsis that is urgently needed.”

UK Sepsis Trust

Ron Daniels

Dr Ron Daniels, chief executive of the UK Sepsis Trust, echoed Mr Behrens’ frustration.

Dr Daniels worked on both the 2013 and 2023 reports, and said it was “disheartening” to see the similarities.

“Ten years on from the 2013 report A Time to Act, our NHS continues to let down too many patients with sepsis,” said Dr Daniels.

“Although progress was certainly made in the years following the report up until the time of the pandemic, not only is it clear that there is significant opportunity for greater improvement but we are also gravely concerned that attention to sepsis is being afforded lower priority in the wake of the pandemic and in an already emburdened NHS.

“With sepsis claiming an estimated 48,000 lives annually in the UK, this report demonstrates that there is an urgent need to establish sepsis as a key priority for healthcare – to get this right will also enable a better approach to antimicrobial stewardship.”

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