Recurring concern
Failure to reliably recognise and respond promptly to sepsis
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Request correctionFirst reported 29 Apr 2014•Latest report 27 Feb 2026
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
- Individual concerns
- 75
- Date range
- 2014–2026
- Stated actions
- 103
Distinct published reports
A report can raise multiple concerns
First to latest report issue date
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.
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.
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Concerns raised1
Failure to recognise the development 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 concernsEach statement is shown once, even when linked to more than one concern.
No linked response statementsNo respondent-stated action or position is linked to these concerns in the published data.
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Concerns raised1
Failure to recognise the urgency of treatment for septic patients
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 concernsEach statement is shown once, even when linked to more than one 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 follow Sepsis Six care bundles in accordance with guidelines
Failure to identify red flag 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 concernsEach 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
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Action
Introduce a bespoke sepsis trolley in the Surgical Assessment Unit for timely treatment.
Stated by the Shrewsbury and Telford Hospital NHS Trust -
Action
Deliver sepsis education across both Emergency Departments, including recognition, screening, Sepsis Six and reference-card reinforcement.
Stated by the Shrewsbury and Telford Hospital NHS Trust -
Action
Review Emergency Department trolleys and assess a trial trolley containing equipment, antibiotics and fluids for immediate sepsis care.
Stated by the Shrewsbury and Telford Hospital NHS Trust
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Action
Develop a Patient Group Directive enabling specified senior nurses to deliver sepsis fluids and antibiotics within one hour when a doctor is unavailable.
Stated by the Shrewsbury and Telford Hospital NHS Trust -
Action
Work with medical teams to train all doctors in sepsis recognition and treatment.
Stated by the Shrewsbury and Telford Hospital NHS Trust -
Action
Create and implement a revised sepsis screening tool in the Surgical Assessment Unit.
Stated by the Shrewsbury and Telford Hospital NHS Trust -
Action
Use Sepsis Champions as Emergency Department links to support staff education with the Critical Care Outreach Team.
Stated by the Shrewsbury and Telford Hospital NHS Trust
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Concerns raised1
Failure of the Paediatric team to recognise and act on sepsis red flag signs
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 concernsEach statement is shown once, even when linked to more than one 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 identify red flag signs of neonatal sepsis
Failure to undertake and record capillary refill time in suspected neonatal sepsis
This report raised 12 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concernsEach statement is shown once, even when linked to more than one concern.
No linked response statementsNo respondent-stated action or position is linked to these concerns in the published data.
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Concerns raised1
Failure to disseminate information that toxins can suppress signs of local inflammation in patients at risk of sepsis
Responses linked to these concernsEach 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
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Action
Disseminate the literature search and the need for heightened suspicion of staphylococcal toxic shock syndrome to all Trust doctors.
Stated by Homerton Healthcare NHS Foundation Trust
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Concerns raised3
Lack of clarity about paediatric sepsis signs and responses
Lack of paediatric sepsis treatment protocol and guidance
Unavailability of a paediatric sepsis screening tool
This report raised 9 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concernsEach 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
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Action
Implement and disseminate an agreed paediatric sepsis toolkit across clinical areas.
Stated by Doncaster and Bassetlaw Teaching Hospitals NHS Foundation Trust -
Action
Provide multidisciplinary training on paediatric sepsis and unexpected deterioration, including training for medical staff during each house induction.
Stated by Doncaster and Bassetlaw Teaching Hospitals NHS Foundation Trust
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Concerns raised1
Failure to use the modified obstetric early warning score tool appropriately to identify 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 concernsEach statement is shown once, even when linked to more than one 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 use a sepsis screening tool in community healthcare
Failure to recognise or adopt a UK sepsis clinical toolkit
This report raised 1 other concern. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concernsEach 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.6
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Action
Introduce updated adult and paediatric sepsis screening tools based on Sepsis 6 red flags and the NHS England safety alert.
Stated by East Midlands Ambulance Service NHS Trust -
Action
Implement the Sepsis 6 pathway at the Loughborough Urgent Care Centre.
Stated by Central Nottinghamshire Clinical Services (CNCS and West Leicestershire Clinical Commissioning Group -
Action
Re-issue sepsis patient safety alert guidance to LLR general practices, including access to adult, paediatric and infant screening and action tools.
Stated by Central Nottinghamshire Clinical Services (CNCS and West Leicestershire Clinical Commissioning Group
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Action
Highlight the importance of diagnosing sepsis and using the sepsis screening tool through the local medical committee.
Stated by NHS England, Midlands & East (Central Midlands -
Action
Develop an approved system for reviewing and implementing patient safety alerts, with subsequent assurance reporting to the Clinical Governance Committee.
Stated by Central Nottinghamshire Clinical Services (CNCS and West Leicestershire Clinical Commissioning Group -
Action
Hold a meeting with University Hospitals of Leicester to share sepsis quality-improvement experience and materials and obtain implementation support.
Stated by Central Nottinghamshire Clinical Services (CNCS and West Leicestershire Clinical Commissioning Group
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Concerns raised1
Failure of newly qualified clinicians to identify sepsis deaths in children
Responses linked to these concernsEach statement is shown once, even when linked to more than one concern.
No linked response statementsNo respondent-stated action or position is linked to these concerns in the published data.
Data last updated 7 September 2026