Urgent Need for Reform: Delays in Sepsis Diagnosis in NHS Highlighted

The Health Services Safety Investigations Body (HSSIB) has issued a stark warning regarding the persistent delays in sepsis diagnosis within the National Health Service (NHS) in England. In a report published on June 27, 2025, HSSIB examined three critical cases where patients suffered severe harm or death due to missed or late diagnoses, underscoring the urgent need for reform in recognition, response, and care coordination for this life-threatening condition.

Sepsis, a severe and potentially fatal condition characterized by the body’s extreme response to infection, affects approximately 245,000 individuals annually in the UK, with around 48,000 deaths attributed to it each year. According to the UK Sepsis Trust, effective learning from these tragic cases could potentially prevent up to 10,000 deaths each year.

The report identified ten key areas requiring improvement, which, while based on the specific cases reviewed, could be applicable across the NHS. "These reports show a consistent pattern of issues surrounding the early recognition and treatment of sepsis," stated Melanie Ottewill, Senior Safety Investigator at HSSIB. Key issues highlighted included poor coordination of care, inconsistent referral pathways, variations in clinical expertise, and challenges in accessing necessary medications.

Significantly, the report noted weaknesses in communication among medical staff and across healthcare organizations. It emphasized the failure to recognize early signs of sepsis, such as new-onset confusion or suspected infection, which are critical indicators of deteriorating health. In two of the three cases investigated, patients displayed new confusion—a recognized red flag—but this symptom went unrecognized by medical staff. Furthermore, families expressed concerns that their observations regarding the patients’ conditions were not taken seriously.

The investigations revealed various breakdowns within the healthcare system. In one instance, a lack of consistent referral processes and inadequate information sharing between hospitals contributed to diagnostic delays. Another case revealed an absence of direct escalation pathways from nursing staff to senior doctors for patients exhibiting deteriorating conditions. Additionally, a delay in prescribing antibiotics by an out-of-hours general practitioner led to a patient waiting nearly 20 hours for treatment, exacerbating their condition.

Dr. Ron Daniels, founder and Chief Medical Officer of the UK Sepsis Trust, emphasized the urgency of swift diagnosis and treatment, stating, "These reports provide a valuable reiteration of how quickly sepsis can develop—and therefore how swift diagnosis and treatment must be." He called for a commitment from health ministers to develop and implement a standardized 'sepsis pathway' to ensure patients receive appropriate care from the moment they present symptoms.

The report also highlighted the importance of listening to families expressing concerns about their loved ones, as they often provide crucial insights into changes in condition. Ottewill noted, "The findings highlight the imperative of listening to families when they express concerns about their loved ones and tell us about changes in how they are."

In conclusion, the HSSIB report serves as a crucial reminder of the ongoing challenges within the NHS in addressing sepsis, a condition that demands immediate and effective intervention. The implications of these findings extend beyond individual cases, reflecting systemic issues that, if not addressed, could continue to compromise patient safety and outcomes in the future.