First reported 29 Apr 2014•Latest report 27 Feb 2026
Definition
What this concern includes
Includes deficiencies in sepsis-related recognition and response across the care process, including dedicated training, awareness, screening tools, clinical assessment, escalation, diagnosis, treatment and monitoring where the report explicitly links the failure to sepsis.
Not included
Excludes generic training, staffing, documentation, communication or governance deficiencies not explicitly tied to sepsis recognition or response.
Excludes concerns about other named hazards or conditions, such as head injury, falls, pressure ulcers or medication safety, unless the report explicitly identifies sepsis recognition or response as the unsafe issue.
Excludes factual statements about sepsis risk that do not identify an unsafe deficiency or unreliable control.
Reports
52
Distinct published reports
Individual concerns
75
A report can raise multiple concerns
Date range
2014–2026
First to latest report issue date
Stated actions
103
Described in published responses
Reports over time
Reports over time
Reports about this concern issued each year.
* 2026 is projected from reports observed to 7 Sep 2026.
Most frequent recipients
Most frequent recipients
Reports about this concern sent to each recipient.
Department of Health and Social Care14
NHS England8
Care Quality Commission7
Barking, Havering and Redbridge University Hospitals NHS Trust3
Doncaster and Bassetlaw Teaching Hospitals NHS Foundation Trust3
Cardiff & Vale University LHB2
Frimley Health NHS Foundation Trust2
Medicines and Healthcare products Regulatory Agency2
NHS Greater Manchester Integrated Care Board2
Tameside and Glossop Integrated Care NHS Foundation Trust2
Abbott Laboratories Limited1
Atrumed Ltd1
Bedfordshire Hospitals NHS Foundation Trust1
Berkshire and Surrey Pathology Services1
Blackpool Teaching Hospitals NHS Foundation Trust1
NHS trust25
Ministerial department15
Executive non-departmental public body10
Healthcare site10
Health and social care service regulator7
Integrated care board6
Private limited company4
Local health board3
Health professional body2
Medicines and medical devices regulator2
Multi-service care provider2
Sub-organisation2
English metropolitan district council1
Health-system partnership1
Independent healthcare provider1
Concerns and responses across reports
Only concerns grouped under this recurring concern are included. Select any concern, action or position to view the source wording.
Essex
Concerns raised2
Failure to follow the Sepsis 6 Pathway
Failure to appropriately recognise signs of sepsis
This report raised 6 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
Actions described in response An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.2
Action
Embed Sepsis 6 prompts, mandatory data fields, treatment-plan completion checks, senior notifications and monthly compliance monitoring within Epic.
Stated by East Suffolk and North Essex NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 18 March 2026.
Action
Deliver mandatory sepsis identification and action training through Trust induction and ongoing top-up sessions for staff across all wards and levels.
Stated by East Suffolk and North Essex NHS Foundation TrustStated in progressThe respondent said that this action was in progress when they made their response on 18 March 2026.
West Yorkshire Eastern
Concerns raised1
Absence of a validated and sufficiently discriminating sepsis screening tool for Paediatric Emergency Departments
This report raised 2 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
Actions described in response An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.2
Action
Roll out the National Paediatric Early Warning System with an integrated sepsis trigger for recognising deterioration in hospitalised children.
Stated by NHS EnglandStated completedThe respondent said that this action was complete when they made their response on 23 February 2026.
Action
Trial an Emergency Department version of the National Paediatric Early Warning System.
Stated by NHS EnglandStated in progressThe respondent said that this action was in progress when they made their response on 23 February 2026.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1
Position
NHS England relies on NPEWS, including its sepsis trigger, rather than introducing a separate national paediatric emergency department sepsis screening tool.
Stated by NHS EnglandExisting arrangements considered sufficientThe respondent said that existing arrangements were sufficient, so no further action was needed.
West Yorkshire Eastern
Concerns raised2
Absence of a validated and sufficiently discriminating sepsis screening tool for escalation in Paediatric Emergency Departments
Failure to consistently deploy the Sepsis Screening Tool across Paediatric Emergency and paediatric in-patient settings
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
Actions described in response An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.1
Action
Update paediatric sepsis guidance in 2026 and consider replacing the traffic-light system with an NPEWS-based approach.
Stated by National Institute for Health and Care ExcellenceStated plannedThe respondent said that this action was planned when they made their response on 19 December 2025.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1
Position
There are several sepsis screening or trigger tools available for use in paediatric emergency departments, contrary to the report’s premise.
Stated by National Institute for Health and Care ExcellenceDisputes the concernThe respondent disagreed with part of the concern or the basis for it.
West Sussex, Brighton and Hove
Concerns raised1
Delays in assessment, diagnosis, treatment and transfer of postoperative sepsis
This report raised 10 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
Actions described in response An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.1
Action
Implement a Care of the Deteriorating Patient policy defining consultant and Resident Medical Officer responsibilities and requiring escalation when consultants fail to respond appropriately.
Stated by Circle Health Group and Goring Hall HospitalStated completedThe respondent said that this action was complete when they made their response on 19 September 2025.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.2
Position
Existing policies sufficiently establish consultants’ continuing responsibility for patients and define RMO and consultant responsibilities during deterioration.
Stated by Circle Health Group and Goring Hall HospitalExisting arrangements considered sufficientThe respondent said that existing arrangements were sufficient, so no further action was needed.
Position
Failures by individual clinicians fall outside prosecutorial remit because prosecutorial powers extend only to registered providers or registered managers.
Stated by Care Quality CommissionOutside remitThe respondent said that this matter was outside its role or authority.
Suffolk
Concerns raised1
Lack of expeditiously developed measures for early identification and treatment of sepsis
This report raised 3 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
Actions described in response An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.1
Action
Fund and support research developing sepsis diagnostics, including point-of-care CRP-VLDL and finger-prick tests.
Stated by Department of Health and Social CareStated in progressThe respondent said that this action was in progress when they made their response on 3 July 2025.
Manchester South
Concerns raised1
Failure to embed the Child Sepsis Screening Tool in assessment and treatment of children and young people
This report raised 4 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
Actions described in response An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.4
Action
Conduct daily PEWS and sepsis audits, share results in safety huddles, review themes weekly and provide targeted training.
Stated by Tameside and Glossop Integrated Care NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 18 June 2025.
Action
Use an electronic triage system with mandated sepsis screening questions that cannot be bypassed.
Stated by Tameside and Glossop Integrated Care NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 18 June 2025.
Action
Maintain annual triage audits and rolling training for practitioners using the Manchester Triage System.
Stated by Tameside and Glossop Integrated Care NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 18 June 2025.
Action
Deliver monthly sepsis simulations and recurring multidisciplinary simulation training for adult and paediatric emergency departments.
Stated by Tameside and Glossop Integrated Care NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 18 June 2025.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1
Position
Existing sepsis training, audits and improvement work demonstrate that the screening tool is embedded among staff assessing and treating children and young people.
Stated by Tameside and Glossop Integrated Care NHS Foundation TrustDisputes the concernThe respondent disagreed with part of the concern or the basis for it.
Manchester South
Concerns raised1
Delays in providing antibiotics in accordance with sepsis needs during high emergency-department demand
This report raised 7 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements
No respondent-stated action or position is linked to these concerns in the published data.
Cornwall and Isles of Scilly
Concerns raised2
Failure to trigger sepsis six and provide required antibiotics when indicated
Absence of a digital alert for the need to implement sepsis six
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
Actions described in response An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.7
Action
Share the patient’s story with AMU staff, focusing on neutropenic sepsis, hypothermia and the sepsis six bundle.
Stated by Royal Cornwall Hospitals NHS TrustStated plannedThe respondent said that this action was planned when they made their response on 9 January 2025.
Action
Convene an AMU educational awayday focused on sepsis and the deteriorating patient.
Stated by Royal Cornwall Hospitals NHS TrustStated in progressThe respondent said that this action was in progress when they made their response on 9 January 2025.
Action
Increase compliance with sepsis training to 80% within four months and 90% within six months, excluding staff on leave.
Stated by Royal Cornwall Hospitals NHS TrustStated plannedThe respondent said that this action was planned when they made their response on 9 January 2025.
Action
Maintain mandatory sepsis training for nurses and healthcare assistants as statutory and essential training.
Stated by Royal Cornwall Hospitals NHS TrustStated completedThe respondent said that this action was complete when they made their response on 9 January 2025.
Action
Provide sepsis update lunchtime training sessions for doctors.
Stated by Royal Cornwall Hospitals NHS TrustStated completedThe respondent said that this action was complete when they made their response on 9 January 2025.
Action
Apply the sepsis screening tool to all blood pressure machines.
Stated by Royal Cornwall Hospitals NHS TrustStated in progressThe respondent said that this action was in progress when they made their response on 9 January 2025.
Action
Develop a sepsis alert within the new e-Care system to digitally flag when the sepsis six should be actioned.
Stated by Royal Cornwall Hospitals NHS TrustStated in progressThe respondent said that this action was in progress when they made their response on 9 January 2025.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1
Position
The current NerveCentre system cannot support a digital sepsis alert, although an alert is planned for the replacement EPR system.
Stated by Royal Cornwall Hospitals NHS TrustUnable to actThe respondent said that a constraint prevented them from taking the relevant action.
Blackpool and the Fylde
Concerns raised2
Delays in providing urgent treatment for suspected sepsis
Failure to recognize suspected sepsis
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
Actions described in response An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.7
Action
Deliver sepsis briefings, safety-huddle and team-meeting teaching, mandated recognition-and-action training, induction training and ward-level knowledge audits.
Stated by Blackpool Teaching Hospitals NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 30 July 2024.
Action
Implement an updated sepsis policy and clinical sepsis proforma aligned with national guidance and the sepsis six.
Stated by Blackpool Teaching Hospitals NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 30 July 2024.
Action
Increase validated sepsis pathway auditing to 40 patients weekly and use identified learning themes to target improvement.
Stated by Blackpool Teaching Hospitals NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 30 July 2024.
Action
Operate a trust-wide sepsis quality-improvement collaborative and disseminate its change package through clinical teams.
Stated by Blackpool Teaching Hospitals NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 30 July 2024.
Action
Hold weekly Emergency Department sepsis review meetings to examine data and drive improvement.
Stated by Blackpool Teaching Hospitals NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 30 July 2024.
Action
Focus the next 12 months of quality-improvement work on escalation pathways through expert forums and trust-wide events.
Stated by Blackpool Teaching Hospitals NHS Foundation TrustStated plannedThe respondent said that this action was planned when they made their response on 30 July 2024.
Action
Submit incidents for delayed sepsis identification, conduct rapid reviews where harm is suspected, and feed identified learning into the sepsis pathway group.
Stated by Blackpool Teaching Hospitals NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 30 July 2024.
East London
Concerns raised2
Failure to treat and escalate suspected sepsis promptly
Failure to identify the extent of gastrostomy leaks and onset of sepsis
This report raised 7 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
Actions described in response An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.5
Action
Provide a dedicated 24-hour, seven-day Critical Care Outreach Team service.
Stated by Barking, Havering and Redbridge University Hospitals NHS TrustStated completedThe respondent said that this action was complete when they made their response on 4 July 2024.
Action
Design and implement Martha’s Rule, enabling patients, relatives and staff to request rapid Critical Care Outreach Team review.
Stated by Barking, Havering and Redbridge University Hospitals NHS TrustStated in progressThe respondent said that this action was in progress when they made their response on 4 July 2024.
Action
Include deteriorating-patient processes and policy in mandatory Basic Life Support training for clinical staff.
Stated by Barking, Havering and Redbridge University Hospitals NHS TrustStated completedThe respondent said that this action was complete when they made their response on 4 July 2024.
Action
Develop online training for recognising deteriorating patients.
Stated by Barking, Havering and Redbridge University Hospitals NHS TrustStated in progressThe respondent said that this action was in progress when they made their response on 4 July 2024.
Action
Operate a weekly deteriorating patient panel to review deterioration and use learning to change practice.
Stated by Barking, Havering and Redbridge University Hospitals NHS TrustStated completedThe respondent said that this action was complete when they made their response on 4 July 2024.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.5
Position
Medical advice and guidance on medical practice or care quality fall outside the respondent’s remit.
Stated by Medicines and Healthcare products Regulatory AgencyOutside remitThe respondent said that this matter was outside its role or authority.
Position
The Trust will respond separately to the concerns about care and processes.
Stated by Department of Health and Social CareRedirects responsibilityThe respondent said that another organisation was responsible for deciding or taking action.
Position
The specific device instructions cannot be reviewed without the gastrostomy device’s brand and manufacturer.
Stated by Medicines and Healthcare products Regulatory AgencyUnable to actThe respondent said that a constraint prevented them from taking the relevant action.
Position
The removed gastrostomy device appeared functional, so no particular device fault appears to require regulatory action.
Stated by Medicines and Healthcare products Regulatory AgencyDisputes the concernThe respondent disagreed with part of the concern or the basis for it.
Position
The MHRA is best placed to address concerns about the gastrostomy device and its product information.
Stated by Department of Health and Social CareRedirects responsibilityThe respondent said that another organisation was responsible for deciding or taking action.
Pin
Get email alerts
Request correction
Includes deficiencies in sepsis-related recognition and response across the care process, including dedicated training, awareness, screening tools, clinical assessment, escalation, diagnosis, treatment and monitoring where the report explicitly links the failure to sepsis.
