Introduction
Sepsis is a life-threatening reaction to an infection. It can affect anyone of any age. It happens when your immune system overreacts to an infection and starts to damage your body’s own tissues and organs. Sepsis is sometimes called septicaemia or blood poisoning.
According to the UK Sepsis Trust, 48,000 people in the UK die of sepsis every year. This number can and should be reduced. It is often treatable if caught quickly.
In this report, we look at some of the sepsis complaints people have brought to us, to shine a light on their experiences and encourage others to let their voices be heard.
We share case summaries and guidance to help people complain and help NHS organisations understand and learn from the issues raised.
Sepsis care and treatment issues
Sepsis is an extremely important patient safety and public health issue. It should be a priority for people involved in providing care and treatment, health regulators and policymakers.
Sepsis causes approximately 1 in 5 deaths globally, with an estimated 49 million cases and 11 million sepsis-related deaths each year. The World Health Organisation is leading worldwide efforts to prevent, manage and treat sepsis. It published a report in 2020 about the global burden of sepsis.
In the UK, an estimated 245,000 cases of sepsis happen each year with deaths totalling more than breast, bowel and prostate cancers combined. The Academy of Medical Royal Colleges has made it clear that: ‘Sepsis still kills far too many people – tens of thousands in the UK each year, and we know that if infection is identified and treated early, some cases of sepsis and some sepsis-related deaths may be preventable.’
The UK Sepsis Trust has been doing invaluable work to improve the outcomes of patients, including publishing ‘The Sepsis Manual’ for medical staff. Health Education England has also been leading on raising awareness of sepsis.
We recognise that significant investments of time and money have been spent to improve sepsis care, with initiatives like Think Sepsis that are helping medical staff to diagnose and treat it. We also recognise that substantial and long-term investment is needed to ensure better outcomes for patients with sepsis.
Evidence from our casework
Ten years ago, our ‘Time to act’ report highlighted the death of ten NHS patients after failure to diagnose and rapidly treat sepsis. We identified issues including:
- unnecessary delays in diagnosing sepsis
- failures in starting treatment quickly
- insufficient staff training
- delayed referrals to critical care
- failure to provide adequate plans for patients’ care.
In response to our recommendations, the National Institute for Health and Care Excellence (NICE) published a guideline (NG51) and quality standard (QS161) to help NHS staff recognise and treat sepsis more quickly. Public Health England (the organisation that was responsible for protecting and improving the nation’s health at that time) and the UK Sepsis Trust launched a national campaign to increase awareness of sepsis symptoms.
Despite some improvements, we still see complaints where we find that someone has died from sepsis because they did not receive the right care at the right time. It is disappointing to see that the issues we identified ten years ago are still the same as we see in our casework today.
Earlier this year, we published ‘Broken trust: making patient safety more than just a promise’. In the cases we looked at in the report, sepsis was the most frequent clinical issue leading to avoidable death. 'Broken trust’ highlighted complex patient safety issues and the need to create a system that is easier to navigate, based on evidence and engagement with patients, families, NHS staff and leaders.
Listening to patients, families and carers
Families affected by sepsis have explained to us that they want what happened to them to matter. They want to make sure voices like theirs are listened to and acted on. They want NHS organisations to make meaningful changes so that what happened to them will not happen to others in future.
In the last ten years, campaigns and training have improved public awareness of sepsis. But we still see too many failings in sepsis care and treatment.
We hope the stories and guidance in this report will help more people share their experiences and understand their right to complain. Our experience gives us evidence every day of the power of complaints. They can make a real difference by showing how the issues are affecting people’s lives and helping organisations to learn from mistakes and improve services for everyone.