A report from the Health Service Ombudsman has said that more must be done to save the lives of patients with sepsis after it found significant failings in treatment of the condition.
Sepsis is caused when the body’s immune system overreacts to infection. It can lead to swelling and blood clotting and can cause internal organs to stop working. Rapid diagnosis and treatment are crucial to survival.
Each year, around 37,000 people are estimated to die of sepsis.
The Ombudsman’s report focused on 10 patients who were not treated urgently enough and died.
The report found that care failings seemed to occur mainly in the first few hours after arriving in hospital. This is the time when rapid diagnosis and simple treatment can be critical to the chances of survival.
Julie Mellow, the Health Service Ombudsman, was reported as saying:
“In the cases in our report, sadly, all patients died. In some of these cases, with better care and treatment, they may have survived. We have worked closely with NHS England, NICE, UK Sepsis Trust and Royal Colleges to find solutions to the issues identified in our report. NICE and NHS England have already agreed to take forward the recommendations of our report. We know it is not easy to spot the early signs of sepsis, but if we learn from these complaints and work to improve diagnosis and provide rapid treatment, then lives can be saved.”
Director of Patient Safety for NHS England, Dr Mike Durkin, said that the NHS would use the findings to work with GPs and hospitals to reduce deaths from sepsis. He was reported as saying:
“This report and guidance will help us to build on the work that is already in place to emphasise the importance of education, early detection and prompt treatment.”
As part of the report, the following key recommendations were made:
- Improving Recognition
NICE will produce guidance to support GPs, ambulance staff and clinicians to recognise sepsis at an early stage, enabling earlier treatment.NHS England will prioritise a workstream on clinical deterioration including the early recognition of sepsis.
The providers of acute services should identify ways in which senior clinical staff become involved in the management of patients with severe sepsis.
NHS England will support the development of a public awareness campaign among vulnerable groups.
Education and training institutions should emphasise the importance of clinical staff listening to relatives of patients.
- Improving Treatment
NICE will include in guidance on sepsis the most clinical and cost effective management of people with severe sepsis.Provider organisations should ensure full integration of available clinical guidance into their own clinical processes and systems to ensure timely treatment.
Provider organisations should foster attitudes and behaviours among their front-line staff which values critical clinical thinking, timely availability of senior decision makers, focused priorities and prompt implementation of clinical plans.
- Continuous improvement
NICE will prepare a quality standard for the management of severe sepsis against which national audit should take place.
- Research
Clinical practice should be underpinned by robust information.
The ability to act quickly when a patient presents with symptoms could potentially save vast amounts of lives. It is clear from the Ombudsman’s findings that it is vital that NHS staff are now provided with the guidance, training and support to enable them to recognise the signs of sepsis quickly.
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