Last week the Health Service Ombudsman’s report “A Time to Act” looking at the problem of sepsis was published. The purpose of the report was to highlight the death of patients in the NHS where there had been a failure to diagnose and rapidly treat severe sepsis.
Sepsis arises where an infection takes hold even in the face of antibiotic therapy. The body is overcome and a rapidly deteriorating and serious illness ensues. It has a high mortality rate. The Sepsis Trust estimates 37,000 people die of sepsis each year. The most common causes of severe sepsis are pneumonia, bowel perforation, urinary infection, and severe skin infections. The leading cause of maternal death is sepsis though it is uncommon. Survivors can face life- changing consequences requiring considerable financial and emotional input.
The report found that existing care standards and protocols were not being followed. In emergency departments sometimes tasks were given differing priorities when in reality a developing sepsis should have been detected and treatment commenced. It was accepted that some patients appear better than they are despite the severity of their illness and only a small proportion of patients become dangerously unwell. Nevertheless important signs were ignored, investigations not undertaken and opportunities for timely treatment missed.
Despite clear current published guidance by the Surviving Sepsis Campaign, the National Institute for Health and Care Excellence (NICE), and other organisations, it appears that in some cases guidelines were not being followed and initial assessments were not being done to the requisite standard.
The report found that failings occurred mainly in the first few hours of sepsis and included failures to take a proper history, to exam the patient, to undertake appropriate tests and to start treatment promptly. There were also failures in handovers and reviews.
None of this information is in fact new. Most of these problems have been identified for some time. The report brings together findings and research but these failures of care have long been recognised. Like all issues the question is why has nothing been done to deal with the situation? Overworked and understaffed departments have in the past been blamed for the failings, but this is not the explanation. There is a general lack of training and experience which doesn’t affect just this area of clinical care. Recent cases here have included clients who have presented with classic signs of sepsis yet no medical or nursing staff considered the possibility.
Nor is the lack of understanding limited to hospital staff. I am currently representing a client whose GP failed to recognise signs of developing sepsis and instead diagnosed iron deficiency anaemia. When he was seen finally by other medics and rushed to hospital it was too late to treat the sepsis without significant complications, most notably loss of limbs.
There exists clear guidance on this issue. The information is readily available and should be used. It is not new. Yet it is ignored. This is not an issue of resources. It is an issue of simple education.
If health workers are to be accountable for their actions then compliance with guidance must be one of the standards by which they are judged. One of the issues clinical negligence lawyers review is whether there is guidance on a topic which identifies tests, investigations and treatment plans for particular conditions. Given the publicity about litigation it is puzzling that this area seems to be neglected.
The Ombudsman has identified additional guidance which NICE can provide for practitioners. However unless there is a will to put it in place, then there is a risk that this will be another example of setting standards which are ignored with obvious legal consequences.