Executive summary
Tragic consequences
This report highlights the death of patients in the NHS after failure to diagnose and rapidly treat severe sepsis. It focuses on ten cases we investigated where patients did not receive the treatment they urgently needed. In every case, tragically, the patient died.
The case stories in this report cover an age range from the first to the eighth decades of life, showing how severe sepsis can strike at any time. They highlight shortcomings in initial assessment and delay in emergency treatment which led to missed opportunities to save lives. They include the tragedy of an active and generally healthy eight-year-old girl whose sepsis was not diagnosed or treated in time, leaving her family with ‘the unbearable pain of losing her’. We also tell the story of a man whose minor operation was complicated by necrotising fasciitis, leading to leg amputation and hospital stay for 15 months, and who never fully recovered after early signs of sepsis were not treated.
From our casebook we have avoided choosing very complex cases. We have anonymised the cases to focus on the wider learning from them. They have in common shortcomings in the care of their illness (at home, in hospital emergency departments, and in hospital wards), and the fact that they have all sadly died. We could have selected many other cases, from different parts of the country.
About sepsis
Bacterial infection is very common, and usually responsive to antibiotics, but in a small proportion of cases infection can overcome the body’s defence mechanisms and progress rapidly to critical illness – known as severe sepsis. Such a situation can be highly challenging to the clinical team providing care. According to the UK Sepsis Trust, 37,000 people are estimated to die of sepsis each year. The most common causes of severe sepsis are pneumonia, bowel perforation, urinary infection, and severe skin infections. Infection complicating childbirth, although less common overall, is the leading cause of direct maternal death.
A complex environment
Existing care standards and protocols are not being followed. Emergency departments are busy and sometimes chaotic places. Staff must often prioritise in difficult circumstances and decide which of several important and urgent tasks they need to do next. This is complicated substantially by the facts that only a small proportion of patients with infection become so critically ill, and people with severe sepsis can be significantly more unwell than they appear.
The standards applied by the Ombudsman in determining whether the care of patients with severe sepsis is reasonable are based on current published guidance by the Surviving Sepsis Campaign, the National Institute for Health and Care Excellence (NICE), and other expert organisations including the General Medical Council (GMC). There is no doubt about the evidence of the need for good initial assessment and immediate basic resuscitation. The readily available Surviving Sepsis Campaign Care Bundles (sepsis care bundles) are evidence‑based and robust.
What we found
Care failings seem to occur mainly in the first few hours when rapid diagnosis and simple treatment can be critical to the chances of survival.
The shortcomings we identified cover both the delivery of clinical care and the way it is organised.
Clinical issues included failure to:
- take a timely history and make a timely examination
- do the necessary tests to quickly identify the source of infection
- monitor regularly
- start important treatment quickly.
- Organisational issues include:
- adequate staff education and training
- ensuring appropriate and timely senior input
- timely referral to critical care
- making and documenting a management plan
- effective handover protocols.
National audits show that clinical standards are not being achieved. For example, in 2012 the College of Emergency Medicine found that their standards for severe sepsis were often not met. None of this is new. These failings have been identified before in previous national reports and various pieces of national guidance and standards.
Saving lives, saving money
Taking action to address these shortcomings does not necessarily require more NHS resource – that is not what we are recommending. Indeed, better care could lead to savings in terms of reduced length of hospital stay and less intensive care and renal dialysis. The UK Sepsis Trust estimates that there are some 100,000 hospital admissions for sepsis each year, with an average cost of about £20,000. Just following basic principles could save £4,000 per episode, and the potential cost saving even after taking account of the increased costs related to improved survival amount to £196 million per year.
Action
We have worked together with NHS England, NICE, the Royal Colleges of Physicians and Surgeons, the College of Emergency Medicine and the UK Sepsis Trust to identify our call to action. We are most grateful for their input.