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More action on sepsis needed as NHS Ombudsman still seeing same failings a decade on

The UK’s Health Ombudsman has warned that sepsis is still taking too many lives due to the same hospital failings we were seeing over ten years ago.

Despite some progress on diagnosis and treatment of sepsis since the publication of our report, Time to act in 2013, lessons are not being learned and repeated mistakes are putting people at risk.

A new report, ‘Spotlight on sepsis: your stories, your rights’, highlights that the same serious failings are still happening, and that significant improvements are urgently needed to avoid more fatalities. Failings include delays in diagnosis and treatment, poor communication and record-keeping, and missed opportunities for follow-up care.

Commenting on the report, Ombudsman Rob Behrens yesterday said:

“I’ve heard some harrowing stories about sepsis through our investigations, and it frustrates and saddens me that the same mistakes we highlighted ten years ago are still occurring. It is clear that lessons are not being learned.

“Complaints have the power to reveal the truth, bring closure and create lasting positive change. But complaints must be handled properly, and findings acted upon. Losing a life through sepsis should not be an inevitability.

“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.”

The report shares Sue’s story. Sue’s mother, Kath, tragically died at Blackpool Teaching Hospitals Trust after sepsis was not recognised and treated.

Kath was diagnosed with pneumonia when she was admitted to hospital in 2017. She developed other lung problems, and almost two weeks later, she fell while in hospital, had a cardiac arrest and sadly died.

Our investigation found Kath showed clear signs of sepsis which caused her health to deteriorate and most likely contributed to her falling. Medical notes showed sepsis was suspected by clinical staff but was not acted upon. The Ombudsman said there was a missed opportunity to identify and treat sepsis which would have likely prevented Kath’s deterioration, and death.

Kath’s daughter Sue yesterday said:

“We were devastated when mum died. When the Ombudsman confirmed that her death was avoidable, it felt like we were grieving all over again. The hospital staff should have recognised the signs of sepsis and acted accordingly. If they had done, mum would probably still be with us now. I took my complaint to the Ombudsman because I don’t want another family to have to go through what we did.”

The report also shares Mrs A’s story. Mrs A was not given antibiotics quickly enough when she fell ill after having an operation on her womb at Sandwell and West Birmingham NHS Trust. She died a few days later and sepsis was recorded as one of the causes of death, along with severe heart failure, which can be caused by sepsis.

The Ombudsman found there was almost a four-hour delay in giving Mrs A antibiotics and she should have been moved to intensive care much earlier than she was. If action had been taken when it should have, Mrs A could have survived.

There are many tragic cases where patients have sadly died, and the outcome could have been different if they, or their families had been listened to. If introduced, Martha’s Rule, which would give people the power to seek an urgent second opinion if a patient's condition was deteriorating, or they have concerns about their care, will play an important role in ensuring patients voices are heard.

Dr Ron Daniels, CEO of the UK Sepsis Trust who’s worked closely with the Ombudsman on this and the previous report, yesterday said:

“It’s incredibly disheartening for me to see that, 10 years on from the 2013 report A Time to Act, our NHS continues to let down too many patients with sepsis. 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.”

The Ombudsman’s concerns echo those he raised earlier this year about the urgent need for trusts to prioritise patient safety to prevent avoidable deaths. Our Broken trust report analysed 22 cases of avoidable death over the last 3 years, 5 of which were due to sepsis. 

The report set out a series of recommendations to improve patient safety, and called on NHS organisations to embed learning cultures that are transparent about mistakes and take accountability for learning from them. It also recommended better support for families affected by harm and getting the right oversight and regulatory structures to prioritise patient safety.


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