World sepsis day
Reports highlight challenges in sepsis diagnosis
World Sepsis Day is held on 13 September every year and is an opportunity for people worldwide to unite in the fight against sepsis. Sepsis accounts for at least 11 million deaths worldwide annually. Recent reports by the Health Services Safety Investigations Body (HSSIB) show that there are still ongoing challenges in ensuring early diagnosis.
Despite extensive national work and awareness campaigns, the recognition of sepsis remains an urgent and persistent safety risk, according to three reports published by HSSIB. The reports also highlight that family members are not always listened to when expressing concerns about a loved one’s condition deteriorating. Each report examined individual cases of sepsis relating to different conditions – in one a patient with diabetes and a foot infection, in another a patient with severe abdominal pain and in the third report an older patient with a urine infection. The investigations were carried out in a different way to HSSIB’s usual approach. They are modelling patient safety incident investigations under the NHS Patient Safety Incident Response Framework (PSIRF) to boost local learning and help improve investigation quality. The patient’s experience is analysed in depth in each report, with input from the healthcare
providers (this spans GPs, hospitals – wards and emergency departments - ambulance services and nursing homes), individual healthcare staff, one of the patients and family members of all the patients.
Lorna arrived at an emergency department
with severe abdominal pain and a fast heart rate. She was admitted to the acute assessment unit in the hospital. She was monitored by staff and various tests were undertaken and treatments given, but she continued to become unwell. When a doctor saw her in person, they recognised the signs of sepsis and antibiotics were given. Sadly, Lorna’s condition continued to worsen, and she died two days after her admission to hospital. Barbara was admitted to a hospital (Hospital A in the report) on 7 June with a severe infection in her right foot. She was referred to a specialist hospital (Hospital B in the report) because of the
poor blood supply to her foot and potential need for vascular surgery. Antibiotics were started but over the course of 3 days Barbara’s foot infection did not improve and there were signs she was becoming more unwell. Barbara was eventually transferred to Hospital B on 11 June. On 12 June, she was found unresponsive and was diagnosed with sepsis. Barbara had to undergo a below the knee amputation to gain control of the infection. She had a complex recovery following the operation, only being discharged in the October.
Ged had suffered a stroke and as result needed help with everyday living which was provided by home carers and his wife. When Ged’s wife went into hospital, Ged had to go into a care home to ensure his care needs were met. While at the home, he was diagnosed with a urine infection. Due to issues with communication and medicine systems, Ged was not given his prescribed antibiotics in a timely manner. When Ged was admitted to hospital with sepsis, he was very unwell and sadly died that same day. While the reports are about different events,
there were some common findings in relation to the recognition of sepsis. The reports reiterate the difficulty of diagnosing sepsis in its early stages and show how quickly person with sepsis can deteriorate. Barbara’s experience highlights the importance of ensuring that people receive specialist care and treatment quickly. Barbara was at high risk of sepsis because of her diabetes and poor blood supply to her foot. All three reports demonstrate the importance
of listening to a family’s concerns about their loved ones – this was particularly apparent in Lorna and Ged’s experiences. Lorna’s family told the HSSIB they didn’t feel heard or listened to despite repeatedly raising their concerns about how unwell she was. Two of the three reports emphasise the importance of confusion as a sign that a person’s health is deteriorating and the importance of involving family members in assessing changes in a patient’s mental state.
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