Foreword from the Ombudsman
This is our first clinical report. It focuses on ten cases we investigated where patients did not receive the treatment they urgently needed. In every case, tragically, the patient died.
Sepsis is a significant cause of death and disability in the UK.
We want complaining to make a difference and so we are publishing our first clinical report. It focuses on ten complaints we investigated about patients with severe sepsis who did not receive the treatment they urgently needed. In every case, tragically the patient died. In some cases, with better care and treatment, they may have survived.
The Ombudsman can support the drive for a patient‑centred NHS by shining a light on issues raised with us by patients and their families. We would like to thank the families in this report who have allowed us to tell their stories.
The crucial lessons to be learnt from this report all derive from concerned people raising complaints about the care received by their loved ones, and pursuing that complaint with us when they do not receive a satisfactory outcome. In doing so they are performing a valuable public service. We know that many do not complain because they feel it will make no difference. Our job is to make sure it does.
We have worked closely with NHS England, NICE, UK Sepsis Trust, the Royal College of Physicians, the Royal College of Surgeons, and the College of Emergency Medicine to find solutions to the issues identified in our report. We are now looking to these organisations and others to make the necessary changes to improve NHS care.
We know it is not easy to spot the early signs of sepsis, but if we learn from these complaints and work to improve diagnosis and provide rapid treatment, then lives can be saved.
Dame Julie Mellor, DBE
Health Service Ombudsman for England
September 2013