Health Service Ombudsman Finds Major Failings In Sepsis NHS Diagnosis And Treatment

13 September 2013

Health Service Ombudsman Finds Major Failings In Sepsis NHS Diagnosis And Treatment

A report from the Health Service Ombudsman has concluded that patients afflicted with sepsis need better diagnosis and treatment in order to save lives in light of startling fatality rates related to inefficient treatment of the condition. The Ombudsman found major failings regarding treatment of sepsis-a condition arising through the body’s immune system being unable to deal with an overreaction in infection. Sepsis can lead to swelling and blood clotting - and cause internal organs to stop working.

The most common causes of severe sepsis are pneumonia, bowel perforation, urinary infection, and severe skin infections.

The Ombudsman, who investigates complaints from people who have received poor service from the NHS in England, said diagnosing and treatment was often hindered as the condition was often difficult to identify and treat. A key finding was that an unacceptable number of deaths had arisen due to poor treatment, inefficient handling of sepsis handling-leading to a present 37,000 deaths annually in the UK alone and delay in the diagnosis, management and treatment of patients with severe sepsis resulting in avoidable death. This was the finding after investigation ten sepsis related deaths, with cases ranging from an eight-year-old girl to an 80-year-old man. All of them died and in each case their family complained to her about the NHS care involved.

Julie Mellor, the Health Service Ombudsman, said it was time for the NHS to act.

"In the cases in our report, sadly, all patients died. In some of these cases, with better care and treatment, they may have survived.

"We have worked closely with NHS England, NICE, UK Sepsis Trust and Royal Colleges to find solutions to the issues identified in our report. NICE and NHS England have already agreed to take forward the recommendations of our report.

"We know it is not easy to spot the early signs of sepsis, but if we learn from these complaints and work to improve diagnosis and provide rapid treatment, then lives can be saved."

The report recommended improving the recognition and treatment of sepsis by providing medical staff with clear clinical guidance.

She also recommended that NHS England launch a public awareness campaign which targets vulnerable groups of patients, such as those who are weak or in hospital.

Around 37,000 people are estimated to die of sepsis each year, accounting for 100,000 hospital admissions.

Clinical staff should attach more importance to listening to the relatives of patients since they can be the first to recognise the patient's deterioration, she said, and more senior doctors should be involved in patient care”

Mellor found that failings in the level of hospital care occurred most often in the first few hours after a patient's arrival in hospital, when rapid identification and treatment is vital to chances of survival.

Shortcomings in clinical care that the Ombudsman identified included:

The failure of staff either to take the patient's history or examine them quickly enough

The failure to initiate diagnostic tests quickly to locate the source of the infection

The failure to monitor the patient's condition regularly and begin treatment in a prompt, time sensitive fashion.

In the case of the eight-year-old girl, she collapsed and died at home the day after a paediatric hospital doctor "missed" two signs that she was seriously ill in an "inadequate" assessment.

Dr Ron Daniels, chairman of the UK Sepsis Trust, said better and more efficient identification and management of the condition could be expedited by adopting guidance measures.

"The best hospitals have achieved better outcomes from sepsis by adopting a simple set of life-saving measures, collectively known as the Sepsis 6, and ensuring that a culture of awareness around sepsis has been created.

"We now need to spread this awareness to other health professionals and to the public, and to underpin this with guidance from NHS England and the National Institute for Health and Care Excellence."

He believes that the recommendations would potentially save 12,500 more lives every year.

Dr Mike Durkin, NHS England's director of patient safety, said these findings were useful in better understanding the nature of the particular problem and dealing with it in a more rapid fashion in the future.

"This report and guidance will help us to build on the work that is already in place to emphasise the importance of education, early detection and prompt treatment.

"We all need in every setting to understand the importance of identifying deterioration in both adults and children, in reducing the admission of full-term babies to neonatal care and identifying problems in vulnerable older people in the first 48 hours of acute illness."

If you have experienced any form of medical mistreatment at any NHS trusts or hospitals, or want to better understand exactly what your patient rights are, we are pleased to offer advice and support to you. Our specialists have wide experience of providing advice and support across a number of areas relating to potential medical mistreatment, such as misdiagnosis and delay and surgery errors, for example.