**Alarming Number of Sepsis Cases Missed as Families’ Warnings Overlooked, Report Warns**
A recent safety investigation has uncovered worrying trends surrounding sepsis diagnosis and patient safety, raising concerns across the UK’s health sector. The Health Services Safety Investigations Body (HSSIB) has detailed its findings in a new report highlighting how delayed recognition and treatment of this potentially fatal condition are costing lives and contributing to avoidable suffering.
Sepsis, a severe reaction to infection where the body’s immune defences attack its own tissues and organs, remains a significant threat in healthcare settings. According to the HSSIB, an estimated 245,000 people across the UK are affected by the condition every year. Despite this, challenges persist in ensuring timely diagnosis—an issue that can have tragic consequences.
The HSSIB’s latest inquiry was informed by three individual cases, each demonstrating the ongoing risks within the health system. Tragically, two people have died, and a third surviving patient endured life-changing injuries due to lapses in early intervention. The stories of Ged, Lorna, and Barbara—whose experiences feature in the report—bring a human face to these systemic failures.
Ged, an older man living in a care home, contracted a urinary tract infection and died from sepsis after he waited nearly 20 hours to receive antibiotics. This delay was attributed to coordination problems between GP out-of-hours services and nursing home staff, exposing critical flaws in healthcare communication.
Similarly, Lorna, a grandmother admitted to an acute assessment unit after arriving at hospital with abdominal pain, succumbed to sepsis. The report observed that understaffing and capacity issues within the assessment unit meant patients, including Lorna, were not always reviewed promptly by doctors. Only after significant time elapsed was she assessed by a clinician, at which point her condition had worsened fatally.
The third case involves Barbara, who suffers from diabetes and developed a foot infection. Although she survived sepsis, she required a below-the-knee amputation in order to control the infection. Questions have since been raised as to whether an earlier hospital transfer and intervention could have prevented the progression to severe sepsis and the need for such a drastic procedure. Barbara spent months in hospital recovering both physically and emotionally from her ordeal.
Importantly, the HSSIB’s review extends beyond the clinical missteps, noting that families of those affected often felt their concerns were not taken seriously by medical staff. According to the report, family members raised alarms about the deteriorating conditions of their loved ones, only for their observations to be overlooked. This sense of not being listened to deepened the trauma experienced by Ged’s and Lorna’s relatives, compounding their grief.
“These reports show a consistent pattern of issues around the early recognition and treatment of sepsis,” explained Melanie Ottewill, a senior safety investigator at the HSSIB. “The experiences recounted in our investigation underscore the devastating outcomes that can arise from sepsis. Our findings highlight the critical importance of listening attentively to families and responding promptly to their concerns.”
Healthcare experts continue to advocate for greater public awareness of sepsis symptoms and rapid intervention. Dr Ron Daniels, founder of the UK Sepsis Trust, stressed the urgency of addressing these failings: “Swift diagnosis and treatment are absolutely crucial—sepsis can escalate rapidly. It’s also vital that members of the public feel entitled to advocate for their relatives, and equally important that clinicians heed their warnings. We desperately need a national commitment to a ‘sepsis pathway’—a standardised plan to guide the management of suspected sepsis cases from the moment of first contact.”
According to the NHS, measures are being implemented to help prevent such incidents from recurring. An NHS England spokesperson pointed to the adoption of Early Warning Systems designed to spot patient deterioration, including sepsis, more reliably. Initiatives such as Martha’s Rule and the use of patient wellness questionnaires are also providing a means for patients and loved ones to escalate their concerns and request urgent reviews if they believe someone is worsening.
The investigation by the HSSIB and the testimonies featured in its report serve as a pointed reminder that lapses in early sepsis detection can have deadly consequences. As awareness grows, the hope is that healthcare professionals and families will work together more cohesively to tackle one of modern medicine’s most challenging emergencies, ultimately saving lives and improving outcomes for thousands each year.