Too many people are still dying from sepsis due to “the same mistakes” highlighted more than 10 years ago, the UK's health ombudsman has warned.
Rob Behrens, who handles complaints about the NHS, said sepsis diagnosis and treatment was taking too long. The UK Sepsis Trust estimates about 48,000 people die each year from sepsis-related illnesses, “thousands” of which are preventable.
NHS England said it was working to improve sepsis management. Sepsis develops when the body's immune system overreacts to an infection and starts attacking its own tissues and organs.
Symptoms can be similar to those of flu and include severe breathlessness and a high fever. In 2013, the ombudsman looked into several sepsis deaths and concluded patients were not being diagnosed or treated quickly enough.
A series of recommendations were made at the time. However, in a new report the service found that although some improvements had been made in the past decade “significant improvements” were urgently needed to avoid more deaths.
‘Harrowing stories'
Mr Behrens found there were still delays in spotting and treating the condition in hospitals. He also identified issues with insufficient staff training, poor communication, poor record-keeping and missed opportunities for follow-up care.
“I've heard some harrowing stories about sepsis through our investigations and it frustrates and saddens me that the same mistakes we highlighted 10 years ago are still occurring,” he said.
Mr Behrens highlighted a series of deaths that he believed may have been preventable. Among the cases he examined was that of a patient named in the report as Kath, who died at Blackpool Teaching Hospitals Trust after being admitted with pneumonia two weeks earlier.
After her death it was revealed that medical notes showed sepsis was suspected by clinical staff but this was not acted upon. This was a “missed opportunity” to spot and treat the condition, Mr Behrens said.
The patient's daughter said the report's findings had left the family “grieving all over again”. Another patient, named in the report as “Ms R”, died of sepsis which developed after she was discharged from hospital, having had bowel cancer surgery.
She had suffered complications in hospital but her recovery was not monitored. The ombudsman concluded her death may have been avoided if follow-up appointments had been arranged.
Mr Behrens also said the NHS needed to “listen to patients and their families when they raise concerns”.
He said: “Crucially, NHS staff must be sepsis-aware.” The UK Sepsis Trust said there was now a need for sepsis to become a “key priority” for healthcare.
Dr Ron Daniels, the charity's CEO, said: “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.”
NHS England said there had been improvements in sepsis care but admitted more work was needed.
In a separate case that was not investigated by the ombudsman, the family of a 16-month-old boy who died from sepsis after hospital failings recently told the BBC their “parental concerns were dismissed” by medics when their son was ill.
James Philliskirk was wrongly diagnosed with chicken pox by doctors at Sheffield Children's Hospital in May 2022. James's mother Helen Philliskirk said: “On both trips to the hospital we feel like it was quite a blinkered approach.”
Recently, the ombudsman said he wanted to see the introduction of “Martha's rule”, which would entitle patients to a second medical opinion about their hospital care. The rule, which is to be introduced by the NHS, is named after 13-year-old Martha Mills, who died from sepsis following a cycling accident in 2021.
An inquest found she would have survived if her care had been better.
— CutC by bbc.com
