Why should you read this?
When something goes wrong in health and social care, the people affected and staff often say, "I don’t want this to happen to anyone else." These 'Learning from safety incidents' resources are designed to do just that. Each one briefly describes a critical issue - what happened, what CQC and the provider have done about it, and the steps you can take to avoid it happening in your service.
Sepsis is a life-threatening reaction to an infection
It happens when the body’s immune system overreacts to an infection and starts to damage internal organs, triggering a chain reaction. It is a medical emergency and is sometimes called septicaemia or blood poisoning.
Anyone can get sepsis. But some people are more likely to get an infection that could lead to sepsis, including babies, people over 75 or who have recently had surgery or a serious illness, and women who have just given birth.
Sepsis can be hard to identify, as symptoms can be vague. Or they can be like other conditions, including flu or chest infections.
Symptoms include:
- blue tinge to lips, skin or tongue
- difficulty breathing
- a rash that does not fade when you roll a glass over it
- acting confused for adults or difficult to wake for babies.
Prosecution by CQC
In 2021, we prosecuted an NHS trust for failing to provide safe care and treatment to two young patients who developed sepsis. Sadly, this led to their deaths within a few weeks of each other in March 2018.
The first patient was a 33-year-old mother of six, who was admitted to the hospital after suffering a week of swelling and pain in her foot.
She died at the hospital two days later from multiple organ failure caused by severe infection.
The second patient was a 14-year-old girl who lived with several complex health conditions from birth. She was admitted to the hospital with diarrhoea and vomiting.
She was transferred to a children’s hospital the next morning where she remained until her death five days later, which was caused by a build-up of fluid on her brain and sepsis.
The care both patients received was undermined by the trust’s failure to address known safety failings in the emergency department that we repeatedly raised with the trust in the months leading up to their deaths.
At prosecution, the trust was found to have failed to act quickly to our concerns. This included failure:
- in the triage process
- to correctly calculate and repeat at correct intervals early warning scores used to improve the detection of sepsis
- to fully implement the sepsis ‘pathway’, which led to delays in beginning treatment
- by the nursing and medical staff to recognise the deterioration in the patients’ conditions.
The court ordered the provider to pay:
- a £2,533,332 fine
- costs of £38,000
- a victim surcharge of £170.
What happened next?
After our inspection in August 2018, the emergency department remained inadequate and we imposed an urgent condition to safeguard patients. We also highlighted areas of poor practice that the trust had to improve, including identifying and managing patients whose condition is deteriorating.
We inspected again in July 2019 and found the emergency department had improved, including its sepsis care and treatment, and we lifted our conditions.
What can you do to avoid this happening?
Sepsis is not uncommon. It is important that it is identified as early as possible so that the appropriate treatment in hospital can be started. People should be assessed by a skilled and competent healthcare professional using agreed tools and processes.
The Royal College of Physicians have developed a National Early Warning Score (NEWS2) to improve the detection and response to clinical deterioration in adult patients, based on normal measurements like pulse rate and blood pressure. NEWS2 has been endorsed by NHS England and NHS Improvement for use in acute and ambulance settings.
The Royal College of Nursing is working in partnership with NHS England and the Royal College of Paediatrics and Child Health (RCPCH) to establish a single National Paediatric Early Warning Score and system (PEWS) for England.
The National Institute for Health and Care Excellence (NICE) produces guidance on the recognition, early diagnosis and treatment of sepsis.
The Royal College of Nursing has produced ‘crib cards’ to help nurses assess for sepsis in hospital and community settings.
The UK Sepsis Trust and NICE have produced clinical tools to support implementation of the NICE guidance for healthcare professionals in all settings.
Learning from safety incidents
Each of these pages describes a critical issue: what happened, what CQC and the provider have done about it, and the steps you can take to avoid it happening in your service.