Sepsis diagnosis failings leading to preventable deaths

Sepsis develops when the body’s immune system overreacts to an infection and starts attacking its own tissues and organs.

The UK sepsis trust estimates five people die every hour from sepsis in the UK, around 48,000 people die every year, including deaths that are preventable if caught and treated quickly.

In 2013, the health service ombudsman investigated several sepsis deaths and concluded patients were not being diagnosed or treated quickly enough. Recommendations were made at the time. However, in a recent report the ombudsman found although some improvements were made, ‘significant improvements’ were needed urgently to avoid more deaths.

Rob Behrens, who handles complaints about the NHS, found through the ombudsman investigation that the same mistakes highlighted 10 years ago are still occurring.

The investigations found that there were still delays in spotting and treating the condition in hospitals, as well as issues such as insufficient staff training, poor communication, poor record keeping and missed opportunities for follow up care.

Multiple cases were reviewed during the investigation, including a series of deaths that could have been prevented had the correct care occurred:

  • A patient named in the report as Kath, died after being admitted to Blackpool teaching hospital with pneumonia two weeks earlier. After her death, it was revealed in medical notes that sepsis was suspected but not acted upon.
  • Another patient named in the report as ‘Mrs R’ died of sepsis due to her recovery from bowel cancer surgery not being monitored.

Mr Behrens said the NHS need to “listen to patients and their families when they raise concerns” and “critically, NHS staff must be sepsis aware”.

The ombudsman wants to see the introduction of “Martha’s Rule”.

Martha’s rule

Martha was on a family holiday in Wales in 2021, when she had a cycling accident and sustained multiple injuries. Martha developed sepsis while being treated in hospital.

Martha was 13 when she died from sepsis.

An inquest into her death found Martha would have survived her injuries, had the hospital’s care been prompt and appropriate.  The hospital admitted mistakes were made and the trust said in a statement that it “remains deeply sorry that we failed Martha when she needed us most”.

Martha’s mother, Merope Mills, felt her family were not listened to by senior doctors on several occasions during her hospital care and were not “given the full picture” about her deteriorating condition, leaving them unable to ask for better treatment.

Merope Mills has been raising awareness for Martha’s rule, since the death of her daughter, which will set up a formal procedure to question and request further opinion regarding medical treatment provided.

If parents, carers, and parents have concerns about their loved ones care, Martha’s rule gives them the right to call for an urgent second clinical opinion from other experts at the same hospital.

After support from Parliament and the Health Service Ombudsman, Martha’s rule is to be introduced by the NHS shortly.

Read our blog here to know the signs and symptoms when spotting sepsis.

Click here to see how Elizabeth Wickson helped John find the answer he sought about the failure of paramedics after his wife’s death caused by sepsis.

More News Stories

Eggs and Embryos Destroyed in Error

Read More
A doctor discussing a child's health with their family, providing medical advice and support.

The introduction of Martha’s Rule

Read More

Meet the Team

Ella Cashion, Paralegal

Ella is dedicated to being an advocate for our clients at Medical Accident Group, guiding them through the legal process offering a supportive hand in what can be an overwhelmingly daunting process.

Find Out More

Contact Us