Recurring concern
Failure to reliably recognise and respond promptly to sepsis
- Reports that mention this concern
- 52
- Times this concern has been raised
- 75
- Stated actions linked to this concern
- 103
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.
What is 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.
Trends
Reports over time
Reports mentioning this concern, 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.
Reports and published responses 52 reports
See individual reports that have raised this concern, and the actions taken in response
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Concerns raised2
Lack of specific sepsis trigger questions on the ambulance pathway
Failure of suspected sepsis indications to trigger a faster ambulance response
This report raised 2 other concerns. They are not shown here because they do not form part of this recurring concern.
Linked response
- NHS England
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1
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NHS England
NHS Pathways already considers sepsis through symptom-based assessment and provides an option to identify suspected sepsis.
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Concerns raised1
Failure to recognise and consider sepsis despite its variable signs and symptoms
This report raised 3 other concerns. They are not shown here because they do not form part of this recurring concern.
Linked responses
- Department of Health and Social Care
- University Hospitals Birmingham NHS Foundation Trust
Stated actions An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.3
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University Hospitals Birmingham NHS Foundation Trust
Deliver a QEHB Emergency Department sepsis training programme with staff champions, educational events, safety-board information and ongoing staff education.
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University Hospitals Birmingham NHS Foundation Trust
Embed sepsis screening in Rapid Assessment and Triage to support recognition across the spectrum of presentation.
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Department of Health and Social Care
Continue working with NHS England to identify resources needed for healthcare professionals to recognise and respond appropriately to patient deterioration.
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Concerns raised1
Failure to follow the Sepsis Protocol
This report raised 3 other concerns. They are not shown here because they do not form part of this recurring concern.
Linked response
- The Trust
Stated actions An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.4
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The Trust
Recruit a Sepsis Lead Nurse responsible for Trust-wide compliance with the Sepsis 6 protocol.
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The Trust
Work towards 100% compliance with Sepsis training across all clinical areas.
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The Trust
Work towards including Sepsis training in mandatory training for clinical staff, with later extension to non-clinical staff.
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The Trust
Continue cyclical Sepsis audits and improvement programmes.
-
Concerns raised2
Lack of a central resource to help families recognise signs of sepsis in patients with darker skin
Knowledge gaps about Down Syndrome-associated immune deficiency and heightened sepsis awareness
This report raised 1 other concern. They are not shown here because they do not form part of this recurring concern.
Linked response
- NHS England
Stated actions An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.4
-
NHS England
Work with stakeholders to raise awareness among families and carers about sepsis signs, including how signs may appear on darker skin.
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NHS England
Review whether to add images or videos to the NHS sepsis page to support recognition of visible symptoms.
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NHS England
Update NHS Down’s syndrome information to clarify increased susceptibility to infection and consequences.
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NHS England
Update NHS sepsis guidance to identify genetic disorders, including Down’s syndrome, as increasing sepsis risk.
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Concerns raised1
Lack of clinician training and education on atypical sepsis presentation and recognition of sepsis with high lactate
This report raised 6 other concerns. They are not shown here because they do not form part of this recurring concern.
Linked response
- Royal Berkshire NHS Foundation Trust
Stated actions An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.1
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Royal Berkshire NHS Foundation Trust
Deliver focused training on atypical sepsis presentation and maintaining a high index of suspicion, particularly with high lactate, in high-prevalence clinical areas.
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Concerns raised1
Failure to commence a diagnostic pathway for suspected sepsis when indicated
This report raised 1 other concern. They are not shown here because they do not form part of this recurring concern.
Linked response
- Barking, Havering and Redbridge University Hospitals NHS Trust
Stated actions An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.5
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Barking, Havering and Redbridge University Hospitals NHS Trust
Use a mandatory electronic sepsis-suspicion field that triggers the sepsis pathway and captures compliance data.
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Barking, Havering and Redbridge University Hospitals NHS Trust
Audit electronic sepsis-suspicion documentation monthly and report compliance through established assurance arrangements.
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Barking, Havering and Redbridge University Hospitals NHS Trust
Update the Trust sepsis education programme and provide additional face-to-face training for doctors and nurses.
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Barking, Havering and Redbridge University Hospitals NHS Trust
Adopt the UK Sepsis Trust adult screening tool and audit its use, high-risk patients and positive blood-culture compliance with the Sepsis 6.
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Barking, Havering and Redbridge University Hospitals NHS Trust
Provide regular weekly sepsis teaching sessions in Acute Medicine across both sites.
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Concerns raised1
Absence of a clear and workable treatment pathway for biliary sepsis
This report raised 4 other concerns. They are not shown here because they do not form part of this recurring concern.
No linked response statementsNo respondent-stated action or position is linked to these concerns in the published data.
-
Concerns raised1
Failure to include Herpes Simplex as a diagnosis to consider in sepsis pathways
This report raised 2 other concerns. They are not shown here because they do not form part of this recurring concern.
Linked responses
- NHS England
- Royal College of Obstetricians and Gynaecologists
Stated actions An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.1
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Royal College of Obstetricians and Gynaecologists
Update the combined maternal sepsis guideline to include timely identification and treatment guidance for herpes simplex, scheduled for publication in March 2024.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.2
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NHS England
National guidance on diagnosing and treating pregnancy-related sepsis and antiviral prescribing is outside the organisation’s remit.
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NHS England
Responsibility for relevant national sepsis guidance lies with the Royal College of Obstetricians and Gynaecologists.
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Concerns raised1
Delays in urgent diagnostic imaging for patients displaying septic shock symptoms
This report raised 14 other concerns. They are not shown here because they do not form part of this recurring concern.
No linked response statementsNo respondent-stated action or position is linked to these concerns in the published data.
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Concerns raised2
Failure to initiate the sepsis protocol effectively
Lack of effective knowledge of the sepsis protocol
This report raised 4 other concerns. They are not shown here because they do not form part of this recurring concern.
No linked response statementsNo respondent-stated action or position is linked to these concerns in the published data.
Actions and positions describe what organisations say in published responses. Implementation is not independently verified.
Data last updated 7 September 2026