Sepsis is a serious condition, with significant medicolegal risk. Dr Pallavi Bradshaw, Education Services Lead (UK) at Medical Protection, looks at where the risk lies
Sepsis, sometimes referred to as the ‘silent killer’, claims more than five million lives per year worldwide[i] and kills more people in the UK than breast, bladder and bowel cancer, and AIDS combined. Despite these figures, a study in Italy, Spain, the UK, France and the United States found that a mean of 88% of people interviewed had never heard of the term ‘sepsis’.[ii]
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.
Where the risk lies
Those particularly at risk include newborns, young children, pregnant women, the elderly and those with a compromised immune system or existing chronic illness. Those who have had surgery are also at more risk of sepsis.
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. A lack of general awareness, education, training and appropriate local protocols are thought to contribute significantly to this delay 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. In 2015, the National Confidential Enquiry into Patient Outcome and Death showed that 40% of people admitted to hospital via A&E were not given a timely review by a clinician, and that less than half of those patients who saw GPs had their temperature or blood pressure taken.
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. Those who are 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, where the patient is a child, bear in mind the concerns of the parents – even if visible signs are subtle, parents know their child better than anyone and are often a reliable indicator of when something is wrong.
- 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 ‘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:
- examination and other relevant clinical findings – include important positives and negatives, and details of objective measurements such as blood pressure
- 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.
Now a contractual obligation 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 A&Es, and those who are already on wards.
- Medics must ask consultants for help 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.
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”.
[ii] Rubulotta FM et al, An international survey: Public awareness and perception of sepsis, Crit Care Med 37(1): 167–70 (2009)