Sepsis is a serious condition, with significant medicolegal risk. Dr Dawn McGuire, Medicolegal Consultant at Medical Protection, looks at where the risk lies.
Sepsis, sometimes referred to as the ‘silent killer’, is estimated to claim 11 million deaths per year worldwide, almost 20% of all global deaths[i] and kills more people in the UK than breast, bladder and bowel cancer, and AIDS combined.[ii]
In the last 10 years, the government, NHS and many organisations have been set up to raise awareness about this silent killer. September has been recognised as Sepsis Awareness month and 13 September crowned Sepsis Awareness Day. A recent Parliamentary and Health Service Ombudsman (PHSO) review calls for greater awareness amongst NHS staff after an avoidable death
Over the years at Medical Protection, we have seen thousands of cases related to sepsis, with a poor outcome resulting in action being taken against the institutions and healthcare workers involved.
Who is most susceptible?
Those particularly at risk include the very young or old, pregnant women, those with a compromised immune system or existing chronic illness – eg diabetes mellitus – and those who have had recent invasive procedures or surgery.
Problems with sepsis stem from delays in its early identification, particularly in the community, and delays in senior review in secondary care and implementing treatment early. General awareness, education, training and appropriate local protocols are therefore crucial to prevent delays in diagnosis and treatment. Early on in the disease, symptoms and signs can be subtle and non-specific, and therefore it is difficult to diagnose.
Not only can sepsis result in significant physical disability and death, but it can also result in the even lesser-known post-sepsis syndrome, in which patients can experience weakness, malaise, pain, anxiety, poor sleep and concentration. Up to 50% of sepsis survivors are affected and those admitted to intensive care are more at risk of this syndrome.
When faced with a potential case of sepsis, the usual medicolegal advice applies:
- Take a comprehensive, detailed history.
- Carry out a thorough examination and record a full set of observations (temperature, heart rate, respiratory rate, level of consciousness, oxygen saturation). In children, bear in mind the concerns of the parents – even if visible signs are subtle.
- Ensure good communication, both verbal and non-verbal, to keep the patient and relatives fully informed in a clear, controlled manner.
- Document the findings, possible diagnosis and discussions with the patient, including clear ‘safety-netting’ advice given to the patient about when to seek more urgent review.
If referring the patient to another healthcare team, the importance of good record keeping and handover to secondary care is essential. Ideally this should cover:
- Relevant medical history
- Examination and other relevant clinical findings – include important positives and negatives, and details of objective measurements such as blood pressure and heart rate
- Differential diagnosis
- Investigations – details of any investigations requested
- Treatment – details of drugs, doses, amount prescribed and any other treatment organised (include the batch number and expiry date of any medications personally administered)
- Past medical and medication history.
So what more can be done? The UK Sepsis Trust has recommended that in primary care, clinicians should be particularly vigilant and consider using the National Early Warning Score (NEWS). It is also recommended that if you have considered sepsis and carried out an assessment – for instance using NEWS – that this is recorded along with safety-netting advice, including what to look out for and how to get help.
Contractual obligation in NHS hospitals in England
From 1 April 2019 sepsis guidance, which NHS England wrote alongside the RCP, the RCGP, NICE, Health Education England, the UK Sepsis Trust and Patient Safety Collaboratives, is now a contractual obligation for English hospitals. As part of the NHS Long Term Plan, the change is being made to potentially save thousands of lives, and says that:
- Staff should look for sepsis at an early stage in patients coming to Emergency Departments, and those who are already on wards.
- Hospital staff must alert senior doctors if patients with suspected sepsis do not respond to treatment within an hour.
- Hospital teams should take sufficient note of non-specific symptoms and concerns expressed by relatives and carers, such as acute changes in behaviour.[iii]
Sepsis is difficult to spot, even for the most experienced clinicians. During the COVID-19 pandemic and subsequent new reality where remote consultations are becoming a norm, it is even more important that clinicians are vigilant to the signs of sepsis and have a very low threshold for offering face-to-face assessments.
Increasingly, many patients have the ability to check their own temperature, heart rate and blood pressure at home, and this should be explored. It may be appropriate to direct patients in the at-risk group reporting abnormal home measurements of vital observations to the Emergency Department immediately. After all, septic shock has a mortality of 7.6% for every hour that antibiotic therapy is delayed.[iv]
Learning from cases
Medical Protection has always been a strong advocate for improving patient safety and is dedicated to equipping doctors with the skills and knowledge to achieve this. As part of this, you can read two case reports on our website that revolve around missed signs of sepsis: “Concealed sepsis” and “Sepsis following chemotherapy” as well as how Medical Protection successfully defends a GP practice in a fatal sepsis case. Note however that this type of primary care claim in England is now handled by NHS Resolution.