NHS failing to learn from fatal sepsis mistakes, watchdog warns

The NHS ombudsman is investigating growing numbers of patients being harmed or dying because of sepsis and has accused hospitals of not learning from mistakes, which have proved fatal.

England’s health ombudsman, Rebecca Hilsenrath, voiced concern about the NHS’s “defensive culture” over the condition, which kills an estimated 48,000 people a year in the UK.

She spoke of her acute anxiety that patients receiving NHS care are still dying avoidably with sepsis –better known as blood poisoning – despite hospitals and GPs being warned repeatedly over many years to get better at spotting and treating it quickly.

The ombudsman looks into cases where a patient or family has complained to an NHS care provider but been dissatisfied with the outcome. She and her staff investigated 44 cases during 2023-24 that involved sepsis, which was the highest number since before the Covid pandemic and 76% up on the 25 cases looked into in 2020-21.

“We share the learning from our casework to help public services improve and prevent the same mistakes happening again. Sadly, when it comes to sepsis, lessons are not being learned, recommendations from reports are not being implemented, and mistakes are putting people at risk.

“The rise in investigations being carried out and upheld is concerning and disheartening, particularly given how many times we have called for action to reduce the number of people being harmed,” Hilsenrath said.

She is particularly worried by the recent spike in cases, she added, because the ombudsman has issued major reports on sepsis care in 2023 and 2013 but not seen the health service do enough to improve staff’s awareness of the condition and the imperative to diagnose it quickly.

“Despite recommendations for improvement, repeated warnings and promises of action, we continue to see mistakes happening. Failure include delays in diagnosis and treatment, poor communication and record-keeping, and missed opportunities for follow-up care,” she said.

NHS trusts are meant to screen any patient suspected to have sepsis and give them antibiotics within an hour of diagnosis to reduce the risk of harm, disability or death. But that does not always happen, sometimes with serious consequences.

Public awareness of sepsis increased in May when the Conservative MP Craig Mackinlay revealed that he had had all his limbs amputated because of the condition, with doctors at one point giving him only a 5% chance of survival.

The NHS needs to undertake “an attitude” over sepsis, added Hilsenrath. Too often it displays a “defensive culture” and lacks “honesty, accountability and responsibility” when mistakes are made over sepsis. In recent cases she has investigated:

A woman brought into the Derby and Burton NHS trust for shortness of breath and dizziness had sepsis diagnosed nine days after her admission and died the next day amid an array of mistakes.

A GP did not spot the signs of sepsis after refusing to visit and assess a 75-year-old man at home in Kent who had a spiking temperature and pains in his back, abdomen and shoulder, and instead dealing with his ailments over the telephone – in breach of NHS care guidelines.

Dr Ron Daniels, an NHS doctor and the founder and joint chief executive of the UK Sepsis Trust, said: “Since the end of the pandemic the NHS has failed to bring monitoring and reporting of sepsis performance and outcome measures back to pre-pandemic levels.

“Over the last 12 months reports, including that from the ombudsman showing a disturbing increase in the number of complaints around sepsis, appear to show that the NHS is now letting people with suspected sepsis fall through the net with alarming regularity, meaning that opportunities to save lives are not being taken.”

Ministers need to ensure that the NHS starts giving sepsis the same priority as other big killers such as heart attacks and strokes, he added.

An NHS spokesperson said that mistakes over sepsis were “rare”.

“All trusts should ensure patients are appropriately screened and receive antibiotics within an hour of a diagnosis of sepsis, and while mistakes are relatively rare, trusts are required to have comprehensive plans for how they respond to and learn from them.

“NHS England has supported the implementation of the National Early Warning Score to improve the recognition and response for all causes of deterioration, including sepsis, as well as patient safety initiatives such as Martha’s Rule, which enables patients and families to seek an urgent review if their condition deteriorates.”