Sepsis is still killing too many patients due to the same hospital failings that occurred a decade ago, a damning report by the NHS ombudsman has warned.
Avoidable mistakes include delays in spotting and treating the condition, poor communication between health staff, sub-standard record keeping and missed opportunities for follow-up care, according to Rob Behrens, the parliamentary and health service ombudsman (PHSO).
Despite some progress since a previous report on sepsis by the ombudsman in 2013, lessons are not being learned and repeated mistakes are putting people at risk, Behrens said. Major improvements are urgently needed to avoid more fatalities, he added.
“I’ve heard some harrowing stories about sepsis through our investigations, and it frustrates and saddens me that the same mistakes we highlighted 10 years ago are still occurring,” said Behrens. “It is clear that lessons are not being learned. Losing a life through sepsis should not be an inevitability.”
Melissa Mead, whose one-year-old son, William, died from sepsis in 2014 after concerns were dismissed by doctors, said: “I think this report, nine years on from William’s death, really lays bare the incidences of sepsis cases.”
Mead, who peer-reviewed the study, added: “Too many lives are being lost in preventable circumstances.”
According to the UK Sepsis Trust, about 48,000 deaths are attributed to sepsis in the UK each year. Its chief executive, Dr Ron Daniels, who also worked with Behrens on the report, said it was “incredibly disheartening” to see the “NHS continues to let down too many patients with sepsis” a decade on from the previous report.
The new report laid out a number of recommendations in a bid to improve patient safety. It also called for NHS organisations to “embed learning cultures that are transparent about mistakes and take accountability for learning from them”, and to better support affected families.
“The NHS needs to listen to patients and their families when they raise concerns,” said Behrens. “It needs to be sepsis-aware.”
Last month, ministers committed to bringing in “Martha’s rule” in England to give patients the right to a second opinion if they believe their concerns were being dismissed by NHS staff.
It follows a campaign by the parents of Martha Mills, who died in 2021 after doctors failed to admit her to intensive care. Martha, 13, died after developing sepsis while under the care of King’s College hospital NHS foundation trust in south London.
Martha’s mother, Merope Mills, an editor at the Guardian, said that she and her husband, Paul Laity, raised concerns about Martha’s deteriorating health a number of times, but that these concerns were not acted upon.
A coroner ruled that Martha, who sustained a pancreatic injury after falling from a bike while on a family holiday in Wales, and who would have turned 16 last month, would probably have survived if doctors had identified the warning signs and transferred her to intensive care earlier.
NHS England said it was working to improve the identification and management of sepsis, and supporting NHS staff to recognise and treat it as quickly as possible.
