Summary of the investigations
These three investigations explore issues associated with sepsis in healthcare settings that span GPs, hospitals, ambulance services and nursing homes. Each report examines an individual case of sepsis relating to different conditions:
- a patient with a urine infection
- a patient with abdominal pain
- a patient with diabetes and a foot infection.
Sepsis is a life-threatening condition that arises when the body’s response to an infection injures its own tissues and organs. Many of those who die in the UK have significant co-existing health conditions. People in certain groups are at higher risk of developing sepsis, for example older people over 75 years or those who have impaired immune function such as people with diabetes. However, other people could potentially survive sepsis if they had the right treatment in a timely manner.
Although sepsis has been the focus of extensive national work, it has persisted as a safety risk. The themes from incidents and complaints have remained the same over time. Evidence from the intelligence gathered suggests that greater insight into the challenges faced at an organisational level in recognising sepsis would be helpful.
To support NHS organisations and local investigation staff, we identified an opportunity to model approaches to patient safety incidents investigations (PSIIs) under the NHS Patient Safety Incident Response Framework (PSIRF). Stakeholders told us that this would help to increase local learning and provide examples of how PSIRF tools can be used to improve investigations. We have also used this opportunity to identify learning that may help to improve how PSIRF can support staff in carrying out incident investigations.
These three investigations used the PSII report template and PSIRF tools to investigate incidents involving patients who developed sepsis. Findings and areas for improvement are listed for the organisations that were involved in these incidents. However, the learning may be relevant to other organisations.
Areas of improvement
Patient with a urine infection
The investigation of a patient with a urine infection identified three areas of improvement which the nursing home and hospital could develop safety actions to address.
Area of improvement 1
Variability in the medical support accessed by nursing staff due to the medical care arrangements for the nursing home.
Area of improvement 2
Difficulty for nursing staff getting medicines prescribed by GPs on the electronic patient record system.
Area of improvement 3
Lack of involvement of families to support the assessment of confusion in patients.
Patient with abdominal pain
The investigation of a patient with abdominal pain identified five areas of improvement.
Area of improvement 1
There is limited understanding and awareness of processes to support family and carer involvement in clinical decision making about deterioration.
Area of improvement 2
New confusion in patients is not consistently accounted for in NEWS2 scores.
Area of improvement 3
Staff perceive that a diagnosis of infection is needed before completing the sepsis screening tool.
Area of improvement 4
There are challenges in how tools and processes enable the care of deteriorating patients to be escalated to, and overseen by, senior medical and nursing staff.
Area of improvement 5
There is variation in the understanding of the role of the critical care outreach team in managing the care and treatment of deteriorating patients.
Patient with diabetes and a foot infection
The investigation of a patient with diabetes and a foot infection identified two areas of improvement which Hospital A and Hospital B could develop safety actions to address.
Area of improvement 1
Review and update the requirements of vascular service provision between Hospital A and Hospital B.
Area of improvement 2
Out of hours expertise in diabetes and foot problems at Hospital A.