NHS fails to learn from fatal sepsis mistakes, watchdog warns
The NHS ombudsman is investigating the rising number of patients suffering harm or dying from sepsis, accusing hospitals of failing to learn from mistakes that have proved fatal.
England’s health ombudsman Rebecca Hilsenrath raised concerns about the NHS’s “defensive culture” around the condition, which kills an estimated 48,000 people a year in the UK.
She spoke of her acute concern that patients receiving NHS care are still dying avoidably from sepsis – more commonly known as blood poisoning – despite hospitals and GPs being repeatedly warned for years to recognise and treat it quickly.
The ombudsman investigates cases where a patient or family has made a complaint to an NHS provider but was unhappy with the outcome. She and her staff investigated 44 cases involving sepsis in 2023-24, the highest number since before the Covid pandemic and 76% more than the 25 cases investigated in 2020-21.
“We share the lessons from our casework to improve public services and prevent the same mistakes from happening again. Unfortunately, in sepsis, lessons are not learned, recommendations from reports are not implemented and mistakes put people at risk.
“The increase in the number of investigations being conducted and enforcement actions being taken is concerning and disheartening, especially given the number of times we have called for action to reduce the number of people being harmed,” Hilsenrath said.
She is particularly concerned about the recent spike in cases, she added, because the ombudsman released major reports on sepsis care in 2023 and 2013, but failed to see that the health service had done enough to improve staff awareness of the condition and the need to diagnose it quickly.
“Despite recommendations for improvement, repeated warnings and promises of action, we continue to see mistakes happen. Failures include delays in diagnosis and treatment, poor communication and administration, and missed opportunities for follow-up care,” she said.
NHS trusts are supposed to screen every patient with suspected sepsis and give them antibiotics within an hour of diagnosis to reduce the risk of harm, disability or death. But that doesn’t always happen, sometimes with serious consequences.
In May, public awareness of sepsis increased when Conservative MP Craig Mackinlay announced that all of his limbs had been amputated due to the condition. At one point, doctors gave him a 5% chance of survival.
The NHS needs to “take a stance” on sepsis, Hilsenrath added. Too often it exhibits a “defensive culture” and lacks “honesty, accountability and responsibility” when mistakes are made about sepsis. In recent cases she has examined:
A woman who was admitted to Derby and Burton NHS Hospital with shortness of breath and dizziness was diagnosed with sepsis nine days after her admission. She died the following day, following a series of errors.
A GP failed to spot the signs of sepsis after refusing to visit and assess a 75-year-old man in Kent at home, who had a high fever and pains in his back, abdomen and shoulder. Instead, he treated his symptoms over the phone, in breach of NHS care guidelines.
Dr Ron Daniels, an NHS doctor and founder and joint CEO of the UK Sepsis Trust, said: “Since the end of the pandemic, the NHS has failed to return monitoring and reporting of sepsis performance and outcomes to pre-pandemic levels.
“Reports over the past 12 months, including from the ombudsman, showing a worrying increase in the number of complaints about sepsis, show that the NHS is now letting people with suspected sepsis slip through the net with alarming regularity, meaning opportunities to save lives are being missed.”
Ministers must ensure the NHS gives sepsis the same priority as other serious causes of death such as heart attacks and strokes, he added.
An NHS spokesman said mistakes about sepsis were “rare”.
“All hospitals should ensure that patients are screened appropriately and given antibiotics within one hour of sepsis diagnosis. Although errors are relatively rare, hospitals should have comprehensive plans for how they respond and learn from them.
“NHS England has supported the implementation of the National Early Warning Score to improve recognition and response to all causes of deterioration, including sepsis, as well as patient safety initiatives such as Martha’s Rule, which enables patients and families to request urgent investigation if their condition deteriorates.”