A new national report has been published by the Health Services Safety Investigations Body (HSSIB), exploring how the NHS Patient Safety Incident Response Framework (PSIRF) can be used to investigate and learn from sepsis-related incidents. The findings highlight key areas for improvement across GP practices, hospitals, ambulance services, and nursing homes.
The investigation focused on three separate patient safety incidents involving sepsis, each linked to different clinical presentations:
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A patient with a urine infection in a nursing home
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A patient with abdominal pain admitted to hospital
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A patient with diabetes and a foot infection treated at two separate hospitals
Sepsis remains a serious safety risk in the NHS, despite years of national initiatives. It is a life-threatening condition that arises when the body’s response to infection causes harm to its own tissues and organs. Individuals over 75 and those with chronic illnesses, such as diabetes, are particularly vulnerable. Yet, many cases are survivable with timely and appropriate intervention.
Common Themes and Systemic Challenges
While each case was unique, the investigations revealed recurring systemic challenges. These included inconsistent escalation processes, difficulty involving families in decision-making, and gaps in clinical knowledge around sepsis recognition and response.
Key findings from the cases include:
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For the nursing home and hospital: Medical support inconsistencies, challenges in prescribing systems, and poor communication with families assessing mental confusion.
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For the hospital managing abdominal pain: Limited staff awareness of family involvement protocols, underuse of early warning score tools (NEWS2) for detecting new confusion, and delayed escalation to senior clinicians.
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For the diabetes and foot infection case: Lack of coordination between vascular services at two hospitals and insufficient out-of-hours specialist expertise.
Using PSIRF Tools for Local Learning
The investigations demonstrate how the PSIRF framework can guide thorough, system-focused investigations. By using PSIRF tools and templates, NHS organisations can conduct patient safety incident investigations (PSIIs) that generate actionable learning and promote consistent standards.
Stakeholders welcomed the report’s practical examples, noting they offer valuable insights for local NHS teams seeking to improve patient safety processes under PSIRF.
“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.”
Moving Forward
The report underscores the importance of addressing organisational-level barriers to sepsis care and reinforces the need for ongoing staff training, robust escalation protocols, and meaningful family engagement.
While the findings were drawn from three individual incidents, the learning is widely applicable across healthcare settings. NHS providers are encouraged to review their internal sepsis management processes in light of these national insights.
For full details, visit the HSSIB Sepsis Investigation Report.
Saving Lives Sepsis: Improving Practice & Outcomes
This conference focuses on ensuring early diagnosis and effective management of Sepsis, and improving outcomes through effective after care following sepsis infection. The conference will update delegates on the implementation of Martha’s Rule and the New national PIER system to improve the management of deterioration.
Date: Friday 28th November 2025 (Virtual)
Details & Register: www.healthcareconferencesuk.co.uk/virtual-online-courses/sepsis-practice
