Recurring concern

Failure to reliably recognise and respond promptly to sepsis

First to latest report 29 Apr 2014 — 27 Feb 2026

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.

Reports and published responses 52 reports

See individual reports that have raised this concern, and the actions taken in response

  1. Surrey

    AI-generated summary

    Maria De Oliveria Alva LOPES · Prevention of Future Deaths report

    This summary was generated using AI from the published report. Please read the original report for the complete account.

    Report summary

    Maria De Oliveria Alva LOPES died on 9 September 2012 after developing severe sepsis from an obstructing ureteric stone, followed by septic shock, multiorgan failure and rhabdomyolysis associated with propofol-related infusion syndrome. The principal concerns included delayed recognition and escalation of sepsis, delays in intensive care admission and treatment, inadequate supervision and control of propofol use, and insufficient monitoring for propofol-related complications.

    Read the report on judiciary.uk

    Source evidence

    How this individual concern was interpreted

    PFD Monitor created a concise, searchable interpretation from the report wording shown below.

    PFD Monitor interpretation

    Failure to recognise and treat sepsis in accordance with national guidelines

    Wider context from the report

    “5. The recognition and treatment of sepsis as per national guidelines ”

    Source location

    Maria De Oliveria Alva LOPES · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

    Source evidence

    How this individual concern was interpreted

    PFD Monitor created a concise, searchable interpretation from the report wording shown below.

    PFD Monitor interpretation

    Failure of critical care outreach to recognise and escalate concerns of sepsis

    Wider context from the report

    “8. Failure to recognise and therefore escalate concerns of sepsis by critical care outreach team ”

    Source location

    Maria De Oliveria Alva LOPES · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

  2. Plymouth, Torbay and South Devon

    AI-generated summary

    Stephen Anthony Allardice Widman · Prevention of Future Deaths report

    This summary was generated using AI from the published report. Please read the original report for the complete account.

    Report summary

    Stephen Anthony Allardice Widman had a history of rectal carcinoma and was repeatedly catheterised. An inappropriately placed catheter was considered likely, infection developed, and he became weakened by pneumonia before dying from sepsis associated with a urinary tract infection and pyelonephritis. Concerns included delays in treating neutropenic sepsis in Accident and Emergency and frequent catheterisation without urological management.

    Read the report on judiciary.uk

    Source evidence

    How this individual concern was interpreted

    PFD Monitor created a concise, searchable interpretation from the report wording shown below.

    PFD Monitor interpretation

    Lack of an accelerated Accident and Emergency pathway for individuals suffering neutropenic sepsis

    Wider context from the report

    “1. There should be an accelerated pathway for individuals suffering neuropenic sepsis so they are dealt with promptly. On the evidence at this Inquest it was inappropriate for the deceased to sit for several hours in the Accident and Emergency Department. 2. The deceased was catheterised too frequently without the management of a urologist. Evidence was received that there is an advantage in treating patients promptly on arrival at Accident and Emergency and that treatment could be expedited if patients were issued with a card noting their vulnerability and bringing with them a contact telephone number. ”

    Source location

    Stephen Anthony Allardice Widman · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

Actions and positions describe what organisations say in published responses. Implementation is not independently verified.

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Data last updated 7 September 2026