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Hospital Failings Behind Too Many Sepsis Deaths: Ombudsman

Sepsis is leading to too many deaths because of the same hospital failings that were seen over 10 years ago, the Parliamentary and Health Service Ombudsman (PHSO) has warned.

Delays in diagnosis and treatment, poor communication and record-keeping, and missed opportunities for follow-up care were identified in a PHSO report which called for urgent and significant improvements to avoid more fatalities. "It is clear that lessons are not being learned," commented Ombudsman Rob Behrens.

The report, Spotlight on sepsis: your stories, your rights, included individual details of when sepsis care went wrong, including that of Sue, whose mother Kath died at Blackpool Teaching Hospitals Trust after sepsis was not recognised and treated. An investigation by the Ombudsman found Kath showed "clear signs" of sepsis and despite medical notes showing sepsis was suspected by clinical staff, it was not acted on.

The report also shared the story of Mrs A who died following uterine surgery at Sandwell and West Birmingham NHS Trust. Her medical notes recorded sepsis as one of the causes of death, along with severe heart failure, which can be caused by sepsis. An investigation by the Ombudsman found Mrs A might have survived if she had been given antibiotics and moved into intensive care sooner.

'Frustrated and Saddened' by the Same Mistakes

Some progress on diagnosis and treatment of sepsis had been made since the publication of a previous PHSO report, Time to Act, in 2013. Nevertheless, Mr 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 10 years ago are still occurring."

The report 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, said he was "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 causing an estimated 48,000 deaths each year in the UK, "this report demonstrates that there is an urgent need to establish sepsis as a key priority for healthcare," he added.

More Work to be Done, Says NHS England

An NHS England spokesperson said: "We are working to improve the identification and management of sepsis, supporting NHS staff to recognise and treat it as quickly as possible, and thanks to an action plan launched in 2017 and our National Early Warning Score helping to spot signs of deterioration, there have been improvements in sepsis diagnosis and treatment."

"However, we know there is more work to be done and patients and families are able to escalate care for hospital patients if they see deterioration or have concerns and, as professional guidance for doctors in England sets out, it is essential that any patient's wishes on this are respected."

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