World sepsis day
All reports highlight areas for improvement that support the early recognition and treatment of sepsis. Although the areas of improvement were directed at the individual organisations involved in the patient safety incidents, the findings and recommended improvements offer valuable insights for all healthcare organisations and staff. These insights can help improve the identification and definition of sepsis when reporting patient safety events and investigating incidents where sepsis is suspected. Melanie Ottewill, Senior Safety Investigator,
said: “These reports provide examples of patient safety incident investigations under the Patient Safety Incident Response Framework (PSIRF). However, they also show a consistent pattern of issues around the early recognition and treatment of sepsis. The experiences of Barbara, Ged and Lorna show the devastating
It’s critical that members of the public feel empowered to act as advocates when their loved ones are unwell, and that healthcare professionals take them seriously. Dr. Ron Daniels, UK Sepsis Trust
consequences of sepsis. They also highlight the imperative of listening to families when they express concerns about their loved one and tell us about changes in how they are. The distress caused by not feeling heard significantly compounded the grief of Ged’s and Lorna’s family. The trauma of their loss was deeply felt throughout their involvement in our investigation. “These findings must be shared widely across NHS Trusts — both for the valuable learning
Guidance and tools to support clinicians to recognise, diagnose and treat sepsis
The National Institute for Health and Care Excellence (NICE) published guidance on the recognition, diagnosis and early management of suspected sepsis in 2016 and this was updated in 2024.
https://www.nice.org.uk/guidance/NG51 The Academy of Medical Royal Colleges
(AoMRC) published a statement on the initial antibiotic treatment of sepsis in 2022.
https://www.aomrc.org.uk/wp-content/ uploads/2022/10/Statement_on_the_initial_ antimicrobial_treatment_of_sepsis_V2_1022.pdf The UK Sepsis Trust has also published
resources and tools to help with the recognition of, and response to, suspected sepsis. https://
sepsistrust.org/ NICE (2024) and AoMRC (2022) guidance
highlights the importance of finding the source of any infection and taking action to control it. Sometimes control is achieved by antibiotic treatment; other times a surgical or drainage procedure may be needed in addition. Both NICE and AoMRC recommend the use
of the ‘national early warning score’ (NEWS2) to assess the risk of severe illness or death from sepsis. NICE guidance makes clear that NEWS2 should be used to support clinical decision making, not to replace clinical judgement. NEWS2 is a scoring tool developed by the Royal College of Physicians (RCP) to improve the detection of, and response to, patients who are becoming more unwell (Royal College of Physicians, 2017).
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www.clinicalservicesjournal.com I September 2025
around sepsis and as a model for patient safety incident investigations under PSIRF. Each report contains detailed analysis and practical insights, offering a significant body of learning for improving patient safety and conducting effective investigations.” Dr. Ron Daniels, Founder and Chief Medical Officer, the UK Sepsis Trust, says: “These reports provide a valuable reiteration of how quickly sepsis can develop (and therefore how swift diagnosis and treatment must be), as well as a reminder of why it’s so important to maintain consistent awareness of every sepsis symptom. It’s critical too that members of the public feel empowered to act as advocates when their loved ones are unwell, and that healthcare professionals take them seriously. “We also need a commitment from health ministers on the development and implementation of a ‘sepsis pathway’ - a standardised treatment plan that ensures patients receive the right care from the point at which they present their symptoms to a clinician through to receiving their diagnosis. By responding effectively and reliably to sepsis, our health service can save lives and improve outcomes for the thousands of people affected by this condition every year.
Download the report at: https://www.hssib.
org.uk/patient-safety-investigations/sepsis- investigating-under-the-patient-safety- incident-response-framework-psirf/
CSJ
Sepsis, bacteria in blood
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