Recognition of sepsis: investigating under the Patient Safety Incident Response Framework (PSIRF)

We have launched three investigations to help address patient safety risks associated with recognition of sepsis.

To support NHS organisations in investigating these types of incidents, HSSIB will model our investigations on the NHS Patient Safety Incident Response Framework (PSIRF) to increase local learning and provide examples of how PSIRF tools can be used to improve investigations.

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.

These investigations will explore what helps, and what hinders, the recognition of sepsis in different care settings.

HSSIB identified the theme of sepsis from reviewing multiple sources of evidence including:

• national incident reporting systems
• academic literature
• national and international publications
• Prevention of Future Deaths (PFD) reports, issued by coroners.

We have also engaged with a wide range of stakeholders, including clinicians and national leads, to learn more about the issues surrounding recognition of sepsis and identify areas where an investigation could focus to help improve patient safety.

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.

The three investigations will focus on what helps, and what hinders, recognition of sepsis in different hospital settings.

The investigations will be carried out at different NHS trusts across England and will provide exemplars of patient safety incident investigations (PSIIs). The guidance and tools produced by NHS England to enable implementation of PSIRF will be used to support the investigations. Any safety actions proposed will be aimed at the specific NHS trusts where the incident occurred.

We expect to publish all three reports together as a sepsis theme in spring 2025.

We are keen to hear from anybody with an interest in this subject matter. This includes patients, families, carers and health and care professionals who may wish to share their experience. If you would like to speak to us about these investigations before we publish the final reports, please email enquiries@hssib.org.uk.