Sepsis Diagnosis Delays Pose Urgent Safety Risk: HSSIB

The Health Services Safety Investigations Body (HSSIB) has warned that delays in diagnosing sepsis continue to pose an “urgent and persistent safety risk” to NHS patients in England. 

In a new report, the independent body examined three cases where patients experienced severe harm or death due to missed or late sepsis diagnoses. The findings highlight continuing challenges faced by clinicians in identifying sepsis early.

The UK Sepsis Trust told The Guardian that learning from such cases could help prevent up to 10,000 deaths each year. Sepsis is associated with around 48,000 deaths and affects approximately 245,000 people each year in the UK.

Key Issues Identified in Sepsis Care 

The HSSIB identified 10 areas for improvement. While based on the three cases reviewed, the recommendations may apply more broadly across the NHS.

“These reports show a consistent pattern of issues around the early recognition and treatment of sepsis,” said Melanie Ottewill, senior safety investigator at the HSSIB.

Key areas for improvement included:

• Poor coordination of care, including inconsistent referral pathways, variation in clinical expertise, and access to medication.
• Weak communication between medical staff and across organisations.
• Failure to recognise early signs such as new-onset confusion or suspected infection.

Case Studies Highlight Diagnostic Challenges 

The three HSSIB investigations involved patients with a urinary tract infection, abdominal pain, and a diabetic foot infection. Two of the patients died. The third required an amputation and faced a long recovery. 

The report emphasised that sepsis symptoms can vary widely, with no single diagnostic tool reliably identifying the condition. Factors such as age, pre-existing health conditions, and immune function can alter how sepsis presents.

In two of the three cases, new confusion — a known red flag — was not recognised. In one case, the patient’s family told investigators they had raised concerns but felt they were not listened to.

Barriers to Timely Treatment

Each investigation uncovered different breakdowns in the system.

One case showed that a lack of consistent referral processes and limited information sharing between hospitals contributed to delayed diagnosis. 

Another case identified the absence of a direct route of escalation from nursing staff to senior doctors for deteriorating patients. It also found that nurses were hesitant to begin a sepsis screen without confirmed signs of infection, which delayed escalation to senior clinicians.

In the third case, a delay in prescribing by an out-of-hours GP using the electronic patient record system meant that a patient waited nearly 20 hours to receive antibiotics.

“These reports provide a valuable reiteration of how quickly sepsis can develop — and therefore how swift diagnosis and treatment must be,” said Dr Ron Daniels, founder and chief medical officer of the UK Sepsis Trust.

“We 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.” 

Ottewill added: “The findings 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.”

Annie Lennon is a medical journalist. Her writing appears on Medscape, WebMD, and Medical News Today, among other outlets.