Beyond Checklists: Listening, Learning And Improving Sepsis Care

In the previous part of this series, I looked at the dangers of “tick box” medicine and why clinical judgement remains essential in sepsis care. In this final part, I consider what meaningful improvement might look like, and why listening to patients and families must remain central to any national framework.

Where the MSF has the potential to improve patient safety

The MSF does, however, have real potential to improve patient safety. The framework seeks to improve data gathering generally, so clinicians can learn from past cases. A national audit programme for infection and sepsis cases, and better data gathering, are of course good things; but only so long as lessons are learned from that data, and it leads to effective change on the ground. I note from the framework that there is not, necessarily, a plan to use the vast wealth of data which NHS Resolution no doubt possesses. In addition to improved clinical data gathering, would it not also be helpful to consider what issues repeatedly arise in sepsis clinical negligence claims and build that into the review?

It further notes that without reliable systems that talk to each other, clinicians may not be able to identify patients who have repeatedly presented over a short period of time. It is hard enough for us as clinical negligence practitioners to pick through the notes and work out the chronology of a patient’s presentation, but if the clinician cannot easily access the notes from previous presentations and work out how and why that patient attended and what the outcome was, how are they meant to offer effective care and recognise a worrying trend? If this exercise results in better electronic patient records, consistent IT systems across Trusts and improved access for clinicians to a patient’s medical records, I am all for it. I will, however, believe it when I see it!

Clearer sepsis guidance and improved training for practitioners is, again, a positive aim. However, I am sure many clinical negligence practitioners have seen inconsistent and unclear guidance. Improving the guidance on the recognition and management of sepsis cannot solely be a case of simply “updating” it. Guidelines need to be clear, straightforward and consistent both nationally and locally, and they ultimately must not act as a replacement for clinical judgement as, inevitably, there will be patients who fall between two sets of guidelines.

From a patient safety perspective, my view is that the most promising aspects of the new framework are those which support earlier recognition of deterioration, better handover, better documentation, learning from serious incident investigation, and improved use of data to identify patterns of harm. All of these things, however, cost money and I do wonder if these laudable aims will be backed up with the funding to make them a reality. If the MSF leads to fewer antibiotics delays, better escalation of care and more consistent senior review, it could make a meaningful difference to outcomes for patients and families affected by sepsis.

The patient and family voice: why listening matters

One of the most important lessons from sepsis cases is the need to listen carefully to patients, parents, carers and families. They may not use medical language, but they often know when something has changed or something is wrong. They may describe a patient as unusually drowsy, confused, clammy, breathless, “not themselves”, or simply much worse than before. Those concerns should not be dismissed because a single observation, score or checklist appears reassuring. This is an all too familiar issue for anyone who has read any of the Ockenden reports into maternity care, but the principles are applicable across the board.

The introduction of Martha’s Rule reflects a wider and very welcome recognition that families must have a meaningful route to escalate concerns when they believe a patient is deteriorating. Where family concerns are ignored, as they were in Martha’s case, escalation is delayed, or deterioration is not properly documented and acted upon, the consequences can be extremely serious. Again, as clinical negligence practitioners we often see disputes between what the family tell us was reported to the clinicians and what was in fact documented. Martha’s Rule empowers patients, their families and staff to call for a rapid review if they feel their concerns are not being responded to.

What might a sepsis negligence claim involve?

A sepsis negligence claim will usually involve a detailed review of the medical records and the decisions made at each stage of the patient’s care. The evidence may include GP notes, ambulance records, emergency department records, nursing notes, observation charts, NEWS2 scores, blood results, lactate levels, microbiology results, medication charts, antibiotic timings, imaging, escalation records, intensive care records, complaint responses, serious incident investigation reports and, in some cases, evidence from an inquest after sepsis.

The legal test is not whether the outcome was poor, but whether there was a breach of duty and whether that breach caused avoidable harm. Expert evidence is therefore essential. A clinical negligence solicitor will usually need to consider whether earlier recognition, earlier antibiotics, earlier senior review, or earlier transfer to critical care would probably have made a difference. These cases can be complex, but they are often highly dependent on the chronology and the missed opportunities within it.

Practical signs that families may wish to investigate further

Families may wish to seek advice from a specialist clinical negligence solicitor if they are left with unanswered questions about sepsis care. Warning signs may include an unexplained delay in antibiotics, repeated patient deterioration without senior review, abnormal observations which were not acted upon, discharge despite worsening symptoms, a failure to follow the Sepsis Six or local sepsis pathway, family concerns being dismissed, missing or inconsistent records, or a complaint response or internal serious incident investigation that does not address the key issues.

In fatal cases, there may also be a coroner’s inquest, or questions about whether the death was avoidable. In non-fatal cases, the impact may still be profound, including prolonged hospital admission, amputation, organ damage, psychological injury, loss of earnings, care needs or long term disability. Early legal advice can help families understand what records should be obtained, what questions should be asked, and whether there may be grounds for a sepsis clinical negligence claim.

Checklists help, but they are not enough

The publication of the MSF for sepsis is therefore a welcome and important development. If it improves consistency, supports earlier recognition, reduces antibiotics delays, strengthens escalation of care and helps the NHS learn from sepsis related harm, it has the potential to save lives. But the future of sepsis management cannot be solely reduced to tick boxes and guidelines alone: they are not a replacement for clinical judgement and treating the patient in front of you.

Checklists, screening tools and pathways are there to support good care, not replace it. The real measure of success will be whether clinicians are given the time, training, staffing and confidence to use any new tools this framework creates intelligently, to recognise when a patient is deteriorating, and to listen when patients and families say that something is wrong. In sepsis care, judgement, compassion and timely action remain just as important as any new framework or set of action points.