Sepsis: life-saving lessons are not being learnt, finds Health Ombudsman

Posted: 07/11/2023

On 30 October 2023, the Health Ombudsman, which is in charge of handling complaints against the NHS, published a new report on sepsis-related deaths. The report found that too many lives are being lost to sepsis because of avoidable mistakes in UK hospitals. The organisation also pointed out that many of these failings were highlighted in a previous report published 10 years ago, suggesting that lessons that could save lives are not being learnt.

Sepsis, which occurs when the body’s immune system reacts to infection, can cause damage to the tissues and organs and lead to serious injury, amputation, organ failure and death if not promptly treated. The new report, entitled Spotlight on Sepsis, sets out several case studies of patients who died from sepsis after failings in their care. The tragic studies included: a woman who passed away due to an abdominal abscess after surgery; a man who developed fatal sepsis from an untreated pressure sore; and a woman who died from pneumonia. In each case, the Health Ombudsman found that deaths could have been prevented with better care.

Issues identified in the report included delays in diagnosing sepsis and providing treatment, delays referring patients to critical care, inadequate care plans and insufficient staff training. Sadly, many of these problems were also found to be present 10 years previously. In 2013, the Health Ombudsman published the Time to Act report on sepsis, which highlighted, among other problems, failures to examine and investigate patients promptly, failures to start treatment on time, and inadequate staff training.

While the 2023 report did find that progress had been made since the Time to Act report, it identified that there was still an urgent need for sepsis to be a key healthcare priority. The Health Ombudsman said in the report: 'Crucially, NHS staff must be sepsis-aware. They also need to have a culture that is open, accepts mistakes when they happen, and then learns from them. It is the responsibility of NHS leadership to build this environment of honesty and accountability. This is a big step in making patient safety an absolute priority.’ It also raised the importance of families’ complaints being listened to, adding that these complaints have the power to ‘reveal the truth, bring closure and create lasting positive change’.

Victoria Johnson, associate in the Penningtons Manches Cooper clinical negligence team, comments: “It is tragic to see that families are losing their loved ones as a result of mistakes that could have been avoided, some of which were raised a decade ago. As the report says, medical staff need to be sepsis-aware, especially when dealing with vulnerable patients such as young children or the elderly. Sepsis can develop very quickly and so prompt diagnosis and treatment is incredibly important to avoid more preventable deaths.”

If you are interested in finding out more about making a clinical negligence claim, you can contact our specialist team on 0800 328 9545, email clinnegspecialist@penningtonslaw.com or complete our online assessment form.

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