Lessons ‘not being learned’ from sepsis failings, ombudsman warns

Hospital failings are leading to too many deaths from sepsis, the NHS ombudsman has warned.

Errors include delays in diagnosing and treating sepsis, poor communication between healthcare staff, sub-standard record keeping and missed opportunities for follow-up care.

An ombudsman report – Spotlight on sepsis: your stories, your rights – follows the publication of a previous document, Time to Act, in 2013.

It said “the same serious failings are still happening” a decade on, and that “significant improvements are urgently needed to avoid more fatalities”.

It added that “action on sepsis” is “urgently needed” and should be shaped by patient experiences.

Ombudsman Rob Behrens said: “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. 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 new report highlights a number of patient stories, including that of Sue, whose mother Kath died after being admitted to Blackpool Teaching Hospitals Trust with pneumonia in 2017.

She developed other lung problems and died two weeks later of cardiac arrest after a fall in hospital.

An investigation by the NHS ombudsman found Kath had signs of sepsis which caused her health to deteriorate. Medical notes also revealed sepsis was suspected by healthcare staff, but was not acted upon.

Sue said her family were “devastated”, adding: “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.”

The report also shares the story of Mrs A, who was not prescribed antibiotics quickly enough when she fell ill after having an operation on her womb at Sandwell and West Birmingham NHS Trust.

She died days later, with the ombudsman finding she should have been moved to intensive care much earlier than she was and would have survived if action had been taken.

Melissa Mead, whose one-year-old son William died from sepsis in 2014 after concerns were dismissed by doctors, peer-reviewed the report.

She told the PA news agency: “I think this report, nine years on from William’s death, really lays bare the incidences of sepsis cases.

“It should, I would hope, with the number of deaths and incidences where families have received sub-standard care or lost their loved ones, encourage the health minister to act now.

“Too many lives are being lost in preventable circumstances.”

According to the UK Sepsis Trust, about 48,000 deaths are attributed to sepsis in the UK each year.

Chief executive Dr Ron Daniels, who founded the charity in 2012, also worked with the NHS ombudsman on the report.

He said it is “incredibly disheartening” to see the “NHS continues to let down too many patients with sepsis” a decade on from the previous report.

“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,” Dr Daniels added.

“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 report has laid out a number of recommendations in a bid to improve patient safety.

It has also called for NHS organisations to “embed learning cultures that are transparent about mistakes and take accountability for learning from them”, as well as better supporting families impacted by these instances.

Mr Behrens said: “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.”

Publication of the report comes after the Government committed to implementing Martha’s Rule in England’s hospitals to give patients the right to a second opinion if they believe their concerns are being dismissed by NHS staff.

Martha Mills, 13, died in 2021 after developing sepsis while under the care of King’s College Hospital NHS Foundation Trust in south London.

In 2022, a coroner ruled she would most likely have survived if doctors had identified the warning signs and transferred her to intensive care earlier.

Her mother, Merope, has since campaigned for more power to be put back into the hands of patients and families.

An NHS England spokesperson said: “We are working to improve the identification and management of sepsis, supporting NHS staff to recognise and treat it as quickly as possible, and thanks to an action plan launched in 2017 and our National Early Warning Score helping to spot signs of deterioration, there have been improvements in sepsis diagnosis and treatment.

“However, we know there is more work to be done and patients and families are able to escalate care for hospital patients if they see deterioration or have concerns and, as professional guidance for doctors in England sets out, it is essential that any patient’s wishes on this are respected.”

The Department of Health and Social Care have been approached for comment.