A new series of HSSIB reports highlight the ongoing challenges in the early diagnosis of sepsis.
Despite extensive national work and awareness campaigns, the recognition of sepsis remains an urgent and persistent safety risk.
A series of three reports from the Health Services Safety Investigations Body (HSSIB) emphasise that patients and family members are not always listened to when expressing concerns about a loved one’s condition deteriorating. Each report examined individual cases of sepsis relating to different conditions – in one, a patient with diabetes and a foot infection; in another, a patient with severe abdominal pain; and, in the third report, an older patient with a urine infection.
The patient’s experience is analysed in depth in each report, with input from the healthcare providers (this spans GPs, hospitals – wards and emergency departments – ambulance services and nursing homes), individual healthcare staff, and one of the family members of all the patients.
“These reports provide examples of patient safety incident investigations under the Patient Safety Incident Response Framework (PSIRF). However, they also show a consistent pattern of issues around the early recognition and treatment of sepsis,” said Melanie Ottewill, senior safety investigator at HSSIB.
Urgent improvements needed
Although the reports are about different events, there were some common findings in relation to the recognition of sepsis.
They reiterate the difficulty of diagnosing sepsis in its early stages and show how quickly a person with sepsis can deteriorate. All three reports demonstrate the importance of listening to a family’s concerns about their loved ones. And two of the three reports emphasise the importance of confusion as a sign that a person’s health is deteriorating and the importance of involving family members in assessing changes in a patient’s mental state.
“These findings must be shared widely across NHS trusts – both for the valuable learning around sepsis and as a model for patient safety incident investigations under PSIRF,” said Ottewill.
In response to the reports, Ron Daniels, founder and chief medical officer at the UK Sepsis Trust, called for a commitment from health ministers on the development and implementation of a standardised treatment plan that ensures patients receive the right care.
“By responding effectively and reliably to sepsis, our health service can save lives and improve outcomes for the thousands of people affected by this condition every year,” he said.
He was backed up by Gemma Bedford, managing associate at Freeths in Nottingham.
“Urgent improvements are imperative to ensure that fatalities are reduced and that these horrendous incidences do not continue to occur,” she said.
