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Time to act, says Ombudsman in report which reveals failings in the urgent treatment of sepsis
37,000 patients die of sepsis each year
A new report by the Health Service Ombudsman, published on World Sepsis Day (13 September), reveals not enough is being done to save the lives of sepsis patients.
The report highlights significant failings in the diagnosis and treatment of severe sepsis. It focuses on ten cases investigated by the Ombudsman where patients did not receive the treatment they urgently needed. In every case, tragically, the patient died.
The stories in this report are of patients ranging from eight to 80 years of age, showing how severe sepsis can strike at any time. They highlight shortcomings in initial assessment and delay in emergency treatment which has led to missed opportunities to save lives.
Complainants highlighted the need for change in the NHS care and treatment of patients:
One complainant said: "Another family must never again experience what we have. This would be a fitting legacy";
Another complainant commented: "Mum would have wanted something to be learned by this and for this not to happen to others."
The Health Service Ombudsman, Julie Mellor, said:
"In the cases in our report, sadly, all patients died. In some of these cases, with better care and treatment, they may have survived. It is time for the NHS to act to save lives by improving the care of patients with sepsis.
"We have worked closely with NHS England, NICE, UK Sepsis Trust and Royal Colleges to find solutions to the issues identified in our report. NICE and NHS England have already agreed to take forward the recommendations of our report. We know it is not easy to spot the early signs of sepsis, but if we learn from these complaints and work to improve diagnosis and provide rapid treatment, then lives can be saved.
"I would like to thank those who have come forward to complain about the poor care received by their loved ones. Their complaints will make a difference for others in the future."
Sepsis accounts for 100,000 hospital admissions each year, with an average cost of about £20,000 each, according to the UK Sepsis Trust. Around 37,000 people are estimated to die of sepsis each year. The most common causes of severe sepsis are pneumonia, bowel perforation, urinary infection, and severe skin infections.
In its report the Ombudsman found that care failings seem to occur mainly in the first few hours after arriving in hospital, when rapid diagnosis and simple treatment can be critical to the chances of survival.
The following recurring shortcomings were noted to be of concern:
lack of timely history and examination (including adequate nurse triage) on presentation
lack of necessary investigations
failure to recognise the severity of the illness
inadequate first-line treatment with fluids and antibiotics
delays in administering first-line treatment
inadequate physiological monitoring of vital signs
delay in source control of infection
delay in senior medical input, and the lack of timely referral to critical care.
The Ombudsman's recommendations include improving recognition of sepsis, as well as treatment, and improvements in auditing and research.
NHS England's Director of Patient Safety, Dr Mike Durkin, said:
"This report is timely and effective in bringing to everyone's attention the importance of this condition and the impact it has on our patients. We will use its findings to work with General Practitioners and Hospitals to reduce the 37,000 deaths that occur each year due to sepsis. The Patient Safety domain within NHS England has many work programmes underway and this report and guidance will help us to build on the work that is already in place to emphasise the importance of education, early detection and prompt treatment.
"We all need in every setting to understand the importance of identifying deterioration in both adults and children, in reducing the admission of full-term babies to neonatal care and identifying problems in vulnerable older people in the first 48 hours of acute illness. By working with partner organisations, both within the NHS and the wider health community, NHS England will continue to give tackling sepsis the priority it deserves."
Dr Ron Daniels, Chair of the UK Sepsis Trust, said:
"Sepsis claims 37,000 lives annually in the United Kingdom, leaving around 70,000 survivors. The best hospitals have achieved better outcomes from sepsis by adopting a simple set of life-saving measures, collectively known as the Sepsis 6, and ensuring that a culture of awareness around sepsis has been created.
"We now need to spread this awareness to other health professionals and to the public, and to underpin this with guidance from NHS England and the National Institute for Health and Care Excellence. The UK Sepsis Trust welcomes this excellent report from the Ombudsman, which exposes common themes where care has failed. With the recommendations arising, together we can save 12,500 more lives every year."
For media enquiries about the Parliamentary Ombudsman Service, including requests for media spokespeople and case studies, please contact the Press Office on 0300 061 4272 / 07825781289 (out of hours) or email firstname.lastname@example.org.
Notes to editors
This report, 'Time to act - Severe sepsis: rapid diagnosis and treatment saves lives', was published on World Sepsis Day (13 September, 2013). It follows expert guidance from the Royal College of Physicians, the College of Emergency Medicine and the UK Sepsis Trust. To download the report, visit: www.ombudsman.org.uk/time-to-act.
As part of the report, the Ombudsman has made the following key recommendations:
1. Improving recognition
1.1 NICE will produce guidance to support GPs, ambulance staff and hospital clinicians to recognise severe sepsis in people at an early stage, so enabling earlier treatment which is known to improve outcomes. This should include the use of early warning scores, good practice in clinical assessment, best use of IT in managing available data, and new technology for near patient investigation (for example to measure blood lactate levels).
1.2 NHS England will prioritise a workstream on clinical deterioration including the early recognition of sepsis, and this may include helping providers of acute services to identify ways by which senior clinical staff are involved in patient management in a timely way.
1.3 The providers of acute services should identify ways by which senior clinical staff become involved early in the management of patients with severe sepsis.
1.4 NHS England will support the development of a public awareness campaign among vulnerable groups such as the immuno-compromised.
1.5 Education and training institutions should emphasise the importance of clinical staff listening to the relatives of patients as they can be the first to recognise the deterioration of the patient.
2. Improving treatment
2.1 NICE will include in guidance on sepsis the most clinical and cost effective management of people with severe sepsis, particularly in relation to the initial recognition and diagnosis of the condition and the timely use of antibiotics and fluid resuscitation.
2.2 Provider organisations should ensure full integration of available clinical guidance into their own clinical processes and systems to ensure timely treatment.
2.3 Provider organisations should foster attitudes and behaviours among their front-line staff which values critical clinical thinking, the timely availability of senior decision makers, focused priorities, and the prompt implementation of clinical plans.
3. Continuous improvement
3.1 NICE will prepare a quality standard for the management of severe sepsis against which national audit should take place. The NHS should ensure appropriate data collection (examples of which should include times from arrival to commencement of fluid resuscitation and antibiotic administration, and the proportion of patients with infection screened for sepsis). This should be mandatory and linked to commissioning arrangements.
4.1 Clinical practice should be underpinned by robust information. Current research questions worthy of sponsorship include optimal fluid replacement; the development clinical tools highly predictive of severe sepsis applicable in primary care; development of near patient investigations applicable out-of-hospital and in emergency departments; and the reasons clinical guidance is not adhered to.
Sepsis is caused when the body's immune system overreacts to infection. It occurs when the body's immune system goes into overdrive, setting off a series of reactions that can lead to widespread inflammation (swelling) and blood clotting. It is an unpredictable condition that can strike at any time. Rapid diagnosis and treatment are critical to survival.
37,000 people are estimated to die of sepsis each year in the UK. The most common causes of severe sepsis are pneumonia, bowel perforation, urinary infection, and severe skin infections.
Sepsis is a more common reason for hospital admission than heart attack – and has a higher mortality.
Care failings seem to occur mainly in the first few hours after arriving in hospital when rapid diagnosis and simple treatment can be critical to the chances of survival.
The UK Sepsis Trust estimates that there are some 100,000 hospital admissions for sepsis each year, with an average cost of about £20,000 each.