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Repeated mistakes in sepsis management are still taking too many lives and significant improvements are urgently needed to avoid more fatalities. according to the UK’s Health Ombudsman.
A new report, ‘Spotlight on sepsis: your stories, your rights’, shows that failings include delays in diagnosis and treatment, poor communication and record-keeping, and missed opportunities for follow-up care.
The Ombudsman highlights that the same serious failings are happening since the publication of its Time to act report in 2013,
Ombudsman Rob Behrens said: “I’ve heard some harrowing stories about sepsis through our investigations, and it frustrates and saddens me that the same mistakes we highlighted ten years ago are still occurring. It is clear that lessons are not being learned.
“Complaints have the power to reveal the truth, bring closure and create lasting positive change. But complaints must be handled properly, and findings acted upon. Losing a life through sepsis should not be an inevitability.
“The NHS needs to listen to patients and their families when they raise concerns. It needs to be sepsis-aware. We know early detection and treatment is crucial. It is time to make sure complaints count, and patients’ voices are used to shape action on sepsis that is urgently needed.”
Sepsis claims an estimated 48,000 lives annually in UK
The report found that there are many tragic cases where patients died, and the outcome could have been different if they, or their families had been listened to. If introduced, Martha’s Rule, which would give people the power to seek an urgent second opinion if a patient’s condition was deteriorating, or they have concerns about their care, will play an important role in ensuring patients voices are heard.
It has set out a series of recommendations to improve patient safety, and called on NHS organisations to embed learning cultures that are transparent about mistakes and take accountability for learning from them. It also recommended better support for families affected by harm and getting the right oversight and regulatory structures to prioritise patient safety.
Dr Ron Daniels, CEO of the UK Sepsis Trust who’s worked closely with the Ombudsman on this and the previous report, said: “It’s incredibly disheartening for me to see that, 10 years on from the 2013 report A Time to Act, our NHS continues to let down too many patients with sepsis. Although progress was certainly made in the years following the report up until the time of the pandemic, not only is it clear that there is significant opportunity for greater improvement but we are also gravely concerned that attention to sepsis is being afforded lower priority in the wake of the pandemic and in an already emburdened NHS.
“With sepsis claiming an estimated 48,000 lives annually in the UK, this report demonstrates that there is an urgent need to establish sepsis as a key priority for healthcare – to get this right will also enable a better approach to antimicrobial stewardship.”
The Ombudsman’s concerns echo those he raised earlier this year about the urgent need for trusts to prioritise patient safety to prevent avoidable deaths. The Broken trust report analysed 22 cases of avoidable death over the last 3 years, 5 of which were due to sepsis.