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Sepsis is causing thousands of deaths a year, a charity has said, as the NHS’s safety watchdog warned that doctors and nurses are too often slow to identify and treat it.
“The recognition of sepsis remains an urgent and persistent safety risk”, despite previous reports highlighting the large number of deaths it causes when diagnosed too late, according to the Health Services Safety Investigations Body.
Too often, relatives were ignored when they raised concerns about the condition of a loved one who later died of sepsis, the HSSIB said on Thursday.
It urged NHS trusts and staff in England to learn from mistakes which the UK Sepsis Trust estimates play a key role in as many as 10,000 avoidable deaths every year UK-wide.
Sepsis develops when an infection goes untreated and the body’s immune response starts to target its own tissues and organs. Doctors refer to that process as “organ dysfunction”.
It causes more deaths than lung cancer and is the second biggest killer in England after heart disease, NHS England says. However, it is very hard to diagnose as many of its symptoms – such as confusion, breathlessness and blotchy skin – are also found with other conditions and there is no single sign or diagnostic test to identify it.
The report from HSSIB is the latest in a series from bodies including the Parliamentary and Health Service Ombudsman (PHSO) and Care Quality Commission to reveal the large number of patients who die every year after NHS staff take too long to diagnose it.
“There have been initiatives to improve the recognition and timely treatment of sepsis over the last 20 years, yet it has persisted as a safety risk,” HSSIB said.
It published reports of three cases involving patients – named only as Barbara, Ged and Lorna – for whom a delay in spotting sepsis had severe consequences. Two of the patients died and the third had to have her leg amputated below the knee after starting on antibiotics too late.
The three incidents “show a consistent pattern of issues around the early recognition and treatment of sepsis”, said Melanie Ottewill, HSSIB’s senior safety investigator.
“The experiences of Barbara, Ged and Lorna show the devastating consequences of sepsis. They also highlight the imperative of listening to families when they express concerns about their loved one and tell us about changes in how they are.”
Lorna was admitted to hospital in England on 5 July last year with severe abdominal pain and a high heart rate. It took 30 hours before a doctor identified her sepsis and gave her antibiotics. However, her condition deteriorated and she died the next day.
“Lorna’s family expressed concerns that they were unable to advocate for her wellbeing and that their concerns about how unwell she was were not always heard,” HSSIB said.
Dr Ron Daniels, the founder and chief medical officer of the UK Sepsis Trust, said that since the success of hospitals in England in 2016-19 at identifying and promptly treating sepsis, the NHS’s performance “has slipped backwards considerably”. That is because a financial incentive offered to hospitals, to screen anyone who might have sepsis and give them antibiotics within an hour – the approach recommended by the National Institute for Health and Care Excellence – ended.
“The quality of care has returned to its pre-2016 level – that is, a postcode lottery in patients’ chances of their sepsis being spotted. I’m appalled,” Daniels said.
“We estimate that of the 48,000 people a year who die of sepsis, at least 10,000 more lives could be saved if the NHS prioritised sepsis as an urgent clinical issue.”
Rebecca Hilsenrath, chief executive of the PHSO, said: “These reports highlight what we have been saying about sepsis for over a decade. Lessons are not being learned, recommendations from reports are not being implemented and mistakes are putting people at risk.”
The NHS’s culture needs to be one that is “open, accepts mistakes and learns from them” in order to reduce the huge toll of avoidable death, she added.
