Over 30 sepsis deaths linked to ‘systemic’ failings, investigation reveals

Major progress made in sepsis care during the previous decade has been significantly reversed amid repeated failures in recognising and treating the condition.

HSJ has identified 31 deaths in the last five years where coroners have warned of systemic problems with diagnosing and treating sepsis, including nine cases relating to children. Many of the deaths were deemed avoidable.

Meanwhile, investigations suggest a majority of acute trusts are failing to record their treatment rates for sepsis, which is deemed a crucial aspect of driving improvements.

Repeated shortcomings raised by coroners, including 10 separate cases in 2023, include delays or failures to administer antibiotics, not following protocols for identifying sepsis, and inaccurate, missed or skipped observations.

Health ombudsman Rob Behrens, who issued a report on sepsis failures last year, said the same mistakes were “clearly being repeated time and time again”.

He added: “What is chilling to me is that these [coroners’ reports] fit in almost exactly with the issues we raised in our sepsis report… and even the 2013 sepsis report issued by my predecessor, including unnecessary delays, wrong diagnosis, and failure to provide adequate plans for sepsis.”

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Source: HSJ, 27 February 2024