Too many patients are dying avoidably from sepsis because hospitals keep making the same mistakes they were a decade ago, the NHS ombudsman has said.
Errors include failing to listen to the concerns of families, delays delivering treatment, poor communication between healthcare staff and bad record keeping.
Sepsis kills about 48,000 people a year in the UK. It happens when the body’s immune system overreacts to an infection, attacking its own tissues and organs.
This can lead to shock, multiple organ failure and death, and symptoms include dizziness, shivering, breathlessness and mottled or clammy skin. It is treated with antibiotics.
A report by Rob Behrens, the parliamentary and health service ombudsman, has highlighted a series of cases where patients have died from sepsis after errors by hospitals.
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The Spotlight on Sepsis report said that “the same serious failings are still happening” as in 2013 when a previous document, Time to Act, called for an overhaul of services.
Behrens said that “significant improvements are urgently needed to avoid more fatalities”, including mechanisms to ensure NHS Trusts are open about mistakes and learn from them.
He added: “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.”
Two years ago Martha Mills died from sepsis aged 13 after failings in her care at King’s College Hospital in south London.
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In 2022 a coroner ruled that Martha would most likely have survived if doctors had identified the warning signs and transferred her to intensive care earlier.
Her mother, Merope Mills, has since led a successful campaign for a new Martha’s rule in England’s hospitals, giving patients and their families a right to second opinions.
The new report highlights patient stories, including that of Sue, whose mother, Kath, died two weeks after being admitted to Blackpool Teaching Hospitals Trust with pneumonia in 2017.
An investigation by the NHS ombudsman found that 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: “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.”
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Melissa Mead, whose son William died aged one from sepsis in 2014 after concerns were dismissed by doctors, peer-reviewed the report.
She said: “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.”
Dr Ron Daniels, chief executive of the UK Sepsis Trust, said it was “incredibly disheartening” to see the “NHS continues to let down too many patients with sepsis”.
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He said: “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 burdened 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.”
An NHS England spokesman 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.”
