Source · HSSIB Patient Safety Investigation
Sepsis: a patient with abdominal pain
Published 26 June 2025
Published
Delayed diagnosis
Hospital care
Patient safety themes
This is the third investigation report we have published to help address patient safety risks associated with sepsis. To support NHS organisations in investigating these types of incidents, HSSIB have modelled 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.
Summary
5 areas of improvement
Areas of Improvement
Area 1
Area
There is limited understanding and awareness of processes to support family and carer involvement in clinical decision making about deterioration.
Area 2
Area
New confusion in patients is not consistently accounted for in NEWS2 scores.
Area 3
Area
Staff perceive that a diagnosis of infection is needed before completing the sepsis screening tool.
Area 4
Area
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 5
Area
There is variation in the understanding of the role of the critical care outreach team in managing the care and treatment of deteriorating patients.