Sepsis is a silent killer, claiming 48,000 lives yearly in the UK. The UK Sepsis Trust recommends basic steps that could save £4,000 per case. Simple actions have a big impact on the fight against sepsis
This report sheds light on a series of tragic cases where patients in the NHS succumbed to severe sepsis due to the failure of timely diagnosis and treatment. It highlights several cases, across various age groups, revealing systemic shortcomings in healthcare that resulted in the unfortunate death of each patient.
About Sepsis
Sepsis, a life-threatening condition, can arise from bacterial infections that overwhelm the body’s defence mechanisms. Despite the prevalence of bacterial infections, a small proportion progresses to severe sepsis, with an estimated 48,000 annual sepsis-related deaths in the UK. The report underscores the common causes of severe sepsis, such as pneumonia, bowel perforation, urinary infection, and severe skin infections.
Identified Failures
Failures in care primarily occur in the critical first few hours when rapid diagnosis and treatment are critical for survival. Both clinical and organizational issues contribute to these shortcomings, including inadequate staff education, delayed senior input, and ineffective handover protocols.
Potential Cost Savings
Addressing these issues could lead to significant cost savings, estimated at £196 million per year. The UK Sepsis Trust suggests that basic principles could save £4,000 per episode, contributing to reduced hospital stays and less intensive care.
Call to Action
The report concludes with a joint call to action involving NHS England, NICE, Royal Colleges, the College of Emergency Medicine, and the UK Sepsis Trust. It urges a collective effort to ensure timely diagnosis and treatment of severe sepsis, emphasizing that sepsis is a more common reason for hospital admission than a heart attack, with a higher mortality rate.
Real Life Case Stories
The following are among the few cases mentioned in the report:
Delayed Diagnosis: Mr. F’s Battle with Sepsis
Mr. F, a 37-year-old family man, tragically lost his life due to severe sepsis after the hospital failed to promptly recognize the seriousness of his condition. Over five days, he experienced symptoms like fever, aches, pains, diarrhoea, vomiting, dizziness, and breathlessness.
Upon reaching the hospital with a rapid pulse, low blood pressure, and rapid breathing, it took one and a half hours for him to see a doctor. A sepsis diagnosis came after three hours, and critical interventions like antibiotics and fluids were delayed. Mr F was moved to intensive care more than eight hours after admission.
Despite efforts, Mr F’s condition worsened rapidly, leading to his tragic demise. Post-mortem revealed overwhelming sepsis as the cause, with the hospital’s delays recognized as significant failings.
Following an investigation, the hospital apologized to Mr F’s wife, providing compensation. Changes were implemented, including a modified early warning score system, sepsis care pathway revision, extra staff recruitment, and adjustments to on-call clinical staff deployment. Mr. F’s wife, despite the challenges, wished for his death to lead to improvements in patient care, a commitment the hospital took seriously.
Lost Time, Lost Life: Mr. E’s Medical Oversight
In a tragic incident, 75-year-old Mr E faced an untimely death due to lapses in medical care. He arrived at the hospital with alarming symptoms, but a four-hour delay before seeing a doctor hindered prompt attention. Diagnosed with pneumonia and sepsis, Mr. E faced further delays in receiving prescribed antibiotics. Overnight, his condition worsened, yet observations were not documented.
The following morning brought tragedy as Mr E experienced a cardiac arrest, leading to intensive care and life support. Despite efforts, complications during a procedure contributed to a fatal cardiac arrest. An investigation revealed significant care shortcomings, prompting the hospital trust to apologize, compensate the family, and implement corrective measures such as enhanced training, revised protocols, increased staffing, and improved leadership.
The family, grieving an unexpected loss, sought not only compensation but systemic changes for future patient safety. The case highlights the need for timely and effective medical care, a policy for medical review before patients leave the emergency department; increased staffing levels; and enhanced clinical leadership.
Missed Signs, Broken Hearts: Child B’s Story
A spirited eight-year-old girl named Child B loved swimming, gymnastics, tap, and ballet. Her weekends were filled with joyous activities until one day, she fell sick with a dry cough. Worried, her family rushed her to the hospital.
Despite her symptoms worsening, the hospital staff missed crucial signs of her serious illness. They suspected various common issues but failed to recognize sepsis. Child B was given paracetamol and sent home.
Tragically, the next morning, Child B collapsed and couldn’t be revived. A post-mortem revealed a bacterial infection causing pneumonia. The hospital admitted its mistakes, apologized and implemented changes to prevent such failings in the future.
Child B’s family, shattered by the loss, hoped that lessons learned from their tragedy would prevent similar heartbreaks. The trust changed following specific measures including developing a paediatric early warning score system and preparing local clinical guidelines on clinical management of children with fever.
Recommendations from the Ombudsman
Improving Recognition
- NICE guidance for early sepsis recognition by GPs, ambulance, and hospital staff.
- Emphasize early warning scores, effective clinical assessment, and new technology.
- NHS England prioritizes clinical deterioration work, involving senior clinical staff promptly.
- Acute service providers to engage senior clinical staff early.
- Support public awareness, especially among vulnerable groups.
Improving Treatment
- NICE guidance on cost-effective severe sepsis management, emphasizing timely interventions.
- Providers integrate clinical guidance for prompt treatment.
- Encourage attitudes valuing critical clinical thinking and timely decision-making.
Continuous Improvement
- NICE develops quality standards for sepsis management.
- Mandate national audit with key indicators linked to commissioning arrangements.
Research
- Prioritize research on fluid replacement, predictive tools, near-patient investigations, and reasons for non-adherence.
In summary, the report shows that there are significant problems in how seriously ill patients, especially those with sepsis, are cared for. We need quick changes in healthcare, like specific areas for improvement including nurse triage, emergency department processes, medical review, and post-admission care. The report also underscores the importance of early warning scores, education, training, research, and appropriate antibiotic use in addressing these challenges. The report suggests that fixing these issues could save money and, more importantly, save lives. The sad stories shared highlight the urgent need for healthcare organizations to work together and improve how they care for patients.
Reference
Welcome to the Parliamentary and Health Service Ombudsman | Parliamentary and Health Service Ombudsman (PHSO). (n.d.). Parliamentary and Health Service Ombudsman. https://www.ombudsman.org.uk/
