HSSIB Sepsis Reports: Three Tragic Cases Reveal NHS Failures

On 26 June 2025, the HSSIB released three in-depth Patient Safety Incident Investigation (PSII) reports under the NHS's Patient Safety Incident Response Framework (PSIRF). Each focuses on a tragic case of sepsis that occurred across different care settings:

1. Patient A – a patient with diabetes and a severe foot infection in general and specialist hospitals.

2. Patient B – an elderly man in a nursing home who developed sepsis from a urinary tract infection.

3. Patient C – a middle-aged individual, experienced severe abdominal pain and received a delayed sepsis diagnosis during their hospital stay.

Why do these reports matter?

• Sepsis is still an urgent safety risk. HSSIB describes sepsis as an "urgent and persistent safety risk," with these cases showing how rapidly it can escalate.
  

• Delayed diagnosis leads to tragic outcomes. Across the cases, two deaths and one limb amputation highlight how crucial early detection and treatment are.
  

• Family concerns are often overlooked. HSSIB identifies a recurring pattern: clinicians dismiss family observations, even when patients experience a marked worsening.
  

• Failures within NHS systems. Communication breakdowns and fragmented care are common issues and occur across hospitals, GPs, nursing homes, and out-of-hours services.
  

• Sepsis care has regressed. Dr Ron Daniels from the UK Sepsis Trust warns that it has dropped back to pre-2016 levels. This change happened after performance incentives were removed.

Key findings & recommended improvements

1. Recognition & definitions: Clarify and align the definitions of "sepsis" and "severe infection" in clinical language. This is important for record-keeping, especially for conditions like "foot sepsis" in diabetics. For more information, please visit hssib.org.uk.
   

2. Tools & pathways: Although tools like NEWS2 and SOFA exist, their integration into frontline decision-making requires reinforcement.
   

3. Communication and coordination: Ensure seamless communication across care interfaces, including hospitals, nursing homes, GPs (in-hours and out-of-hours), and ambulance services. Act on family-reported signs and concerns — they frequently represent critical early warnings
   

4. System capacity & oversight: This is important when they provide care in local and regional services. Vascular support is an example of such services. Strengthen "hubandspoke" models to reduce variability in clinical decisions.
   

5. Working under PSIRF: These reports show how PSIRF can help investigate safety events. The goal is not to blame anyone. Instead, we want to improve systems using a non-punitive and learning-focused approach. By exposing systemic flaws, HSSIB aims to help NHS trusts embed better safety investigation practices and learning cultures.

Broader context & impact

Sepsis is a major health problem. It kills more people than lung cancer. In England, it is the second biggest killer after heart disease. Every year, sepsis causes about 48,000 deaths in the UK. Doctors believe at least 10,000 of these deaths could be avoided.

Systemic underflow: Despite persistent warnings (e.g., from the Parliamentary Ombudsman in 2023), widespread progress has failed to materialise, highlighting systemic inertia. theguardian.com

Policy initiatives: The reports suggest a standard "sepsis pathway." This pathway includes recognising symptoms, triage, diagnosis, and treatment. Training, protocols, and accountability measures should support it.

What should happen next?

1. Health trusts must review these findings and implement safety actions, including training, communication improvements, and clarity of clinical pathways.

2. Embed family-led escalation policies like "Martha's Rule." This means that when family members raise early concerns, it triggers a quick clinical review.

3. Reintroduce performance incentives for sepsis screening, diagnosis, and treatment timelines to improve outcomes.

4. Roll out PSIRF-led safety investigations nationwide, fostering a culture of learning rather than blame.

In summary

The HSSIB's three PSII reports on sepsis show a harsh truth. Despite years of advice, many people are still dying. This is because of slow recognition, poor communication, and missed early treatment opportunities.

These investigations reframe the conversation, shifting the focus from apportioning blame to tackling system-wide vulnerabilities head-on. The goal is that by learning from these three stories, the NHS can quickly improve sepsis care. This will help restore attention to patients and ultimately save lives.

Key news coverage of HSSIB sepsis investigation reports:

Patients dying of sepsis because medics too slow to spot it, warns NHS watchdog The Guardian

Martha's Rule saving lives as families use right to second opinion The Times