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.
South Wales Central
Concerns raised1
Failure to ensure that patients and carers understand the specific signs of 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.5
Action
Ensure new patients seen by the ANA team receive updated sepsis-sign information, supplying the literature when patients do not have it.
Stated by Abbott Laboratories LimitedStated plannedThe respondent said that this action was planned when they made their response on 19 December 2022.
Action
Carry and share Adult and Paediatric Symptom Cards with patients showing infection signs and their relevant family members or carers.
Stated by Abbott Laboratories LimitedStated plannedThe respondent said that this action was planned when they made their response on 19 December 2022.
Action
Update PEG patient and family information to include sepsis signs and symptoms, and provide it to new patients.
Stated by Cardiff & Vale University LHBStated completedThe respondent said that this action was complete when they made their response on 19 December 2022.
Action
Consider suitable generic sepsis information for use at the procedure and later in the community, including a credit-card-sized symptom card.
Stated by Cardiff & Vale University LHBStated in progressThe respondent said that this action was in progress when they made their response on 19 December 2022.
Action
Provide sepsis symptom cards to children and their parents to promote awareness of childhood sepsis signs and symptoms.
Stated by Cardiff & Vale University LHBStated plannedThe respondent said that this action was planned when they made their response on 19 December 2022.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.2
Position
Patient information may only be issued when authorised by Cardiff and Vale UHB under the existing contract specification.
Stated by Abbott Laboratories LimitedOutside remitThe respondent said that this matter was outside its role or authority.
Position
Cardiff and Vale UHB is responsible for updating patient information and purchasing symptom cards addressing sepsis signs.
Stated by Abbott Laboratories LimitedRedirects responsibilityThe respondent said that another organisation was responsible for deciding or taking action.
Manchester South
Concerns raised2
Lack of awareness of neutropenic sepsis guidance and red flags
Failure of triage to prompt for neutropenic 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.
No linked response statements
No respondent-stated action or position is linked to these concerns in the published data.
Manchester City
Concerns raised3
Failure to appropriately recognise sepsis
Failure of new, locum and agency staff to act in accordance with sepsis protocols and policies
Delays in commencing appropriate sepsis treatment
This report raised 5 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.6
Action
Implement HIVE with sepsis screening alerts, escalation prompts, Sepsis Six guidance and treatment timing support.
Stated by Manchester University NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 4 October 2022.
Action
Establish an eight-member Acute Care team to deliver sepsis education, quality improvement and monthly compliance review across the Trust.
Stated by Manchester University NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 4 October 2022.
Action
Publish acute-care education guidelines and require relevant clinical, nursing and medical staff to complete sepsis-related induction, mandatory and role-specific training.
Stated by Manchester University NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 4 October 2022.
Action
Establish inpatient sepsis audits and present findings to the Clinical Effectiveness Committee to monitor recognition and timely treatment.
Stated by Manchester University NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 4 October 2022.
Action
Establish a Sepsis Task and Finish Group to improve sepsis education and awareness and use HIVE data to monitor screening compliance.
Stated by Manchester University NHS Foundation TrustStatus unclearThe respondent did not make the status of this action clear when they made their response on 4 October 2022.
Action
Provide NHS Professionals, locum and agency staff with induction or local orientation covering HIVE, sepsis policies, procedures and relevant mandatory training before or during shifts.
Stated by Manchester University NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 4 October 2022.
Manchester South
Concerns raised3
Failure to flag sepsis concerns in patient notes
Failure to escalate non-compliance with the sepsis policy
Failure to place sepsis-triggering patients on the sepsis pathway
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.7
Action
Conduct monthly internal spot-check audits of sepsis pathway compliance and report non-compliance through incident forms.
Stated by Tameside and Glossop Integrated Care NHS Foundation TrustStated in progressThe respondent said that this action was in progress when they made their response on 30 September 2022.
Action
Run a Trust-wide incident-reporting programme addressing incident and near-miss identification, reporting, learning and action.
Stated by Tameside and Glossop Integrated Care NHS Foundation TrustStated in progressThe respondent said that this action was in progress when they made their response on 30 September 2022.
Action
Continue working with AoMRC and NICE to consider how healthcare professionals will be educated and informed about updated national sepsis guidance.
Stated by Department of Health and Social CareStated in progressThe respondent said that this action was in progress when they made their response on 30 September 2022.
Action
Continue working with the National Institute for Health and Care Research to understand evidence and evaluation that may support implementation of new sepsis guidance.
Stated by Department of Health and Social CareStated in progressThe respondent said that this action was in progress when they made their response on 30 September 2022.
Action
Implement a Trust-wide sepsis improvement programme covering recognition, Sepsis Care Bundle use, antibiotics, blood cultures and deteriorating-patient assessment.
Stated by Tameside and Glossop Integrated Care NHS Foundation TrustStated in progressThe respondent said that this action was in progress when they made their response on 30 September 2022.
Action
Deliver sepsis awareness, training and dissemination activities through briefings, scenario sessions, toolbox talks and sharing learning with clinical teams.
Stated by Tameside and Glossop Integrated Care NHS Foundation TrustStated in progressThe respondent said that this action was in progress when they made their response on 30 September 2022.
Action
Agree additional nursing posts to support sepsis identification, training and compliance across the organisation.
Stated by Tameside and Glossop Integrated Care NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 30 September 2022.
Blackpool and the Fylde
Concerns raised1
Failure to consider and initiate sepsis protocols following Early Medical Abortion
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 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
Work closely with NHS England to ensure adherence to national guidance for detecting and managing sepsis-related deterioration.
Stated by Department of Health and Social CareStated in progressThe respondent said that this action was in progress when they made their response on 17 May 2022.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1
Position
Relevant medical Royal Colleges set postgraduate trainee doctors’ curricula, subject to standards set by the General Medical Council.
Stated by Department of Health and Social CareRedirects responsibilityThe respondent said that another organisation was responsible for deciding or taking action.
Bedfordshire and Luton
Concerns raised1
Failure of the sepsis template to operate reliably and mandatorily
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.2
Action
Upgrade the software module and add a Sepsis Screening tool that flags abnormal observations indicating sepsis risk.
Stated by Atrumed LtdStated completedThe respondent said that this action was complete when they made their response on 26 April 2022.
Action
Require clinical practitioners to use the Sepsis Screening tool under Atrumed’s local policy.
Stated by Atrumed LtdStated completedThe respondent said that this action was complete when they made their response on 26 April 2022.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1
Position
The underlying System One sepsis-template function is outside Atrumed’s control, limiting its ability to alter that software directly.
Stated by Atrumed LtdUnable to actThe respondent said that a constraint prevented them from taking the relevant action.
Surrey
Concerns raised1
Failure to recognise signs 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.
No linked response statements
No respondent-stated action or position is linked to these concerns in the published data.
Surrey
Concerns raised1
Inadequate training and understanding about sepsis in elderly people
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.
No linked response statements
No respondent-stated action or position is linked to these concerns in the published data.
Nottinghamshire
Concerns raised1
Low compliance with the paediatric sepsis screening tool
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.12
Action
Monitor paediatric sepsis-screening compliance through quarterly audits and report results to clinical governance and quality committees.
Stated by Doncaster and Bassetlaw Teaching Hospitals NHS Foundation TrustStated in progressThe respondent said that this action was in progress when they made their response on 3 August 2021.
Action
Disseminate sepsis-learning and screening-tool messages through staff memoranda, the monthly Matron Newsletter and Clinical Governance meeting records.
Stated by Doncaster and Bassetlaw Teaching Hospitals NHS Foundation TrustStated in progressThe respondent said that this action was in progress when they made their response on 3 August 2021.
Action
Develop and pilot a multidisciplinary sepsis audit tool covering the pathway from Emergency Department arrival.
Stated by Doncaster and Bassetlaw Teaching Hospitals NHS Foundation TrustStated in progressThe respondent said that this action was in progress when they made their response on 3 August 2021.
Action
Review and approve the sepsis screening and action tool standard operating procedure through the specialty Clinical Governance meeting.
Stated by Doncaster and Bassetlaw Teaching Hospitals NHS Foundation TrustStated in progressThe respondent said that this action was in progress when they made their response on 3 August 2021.
Action
Complete weekly assurance audits of clinical records across acute areas, covering sepsis assessment and related discharge and communication safeguards.
Stated by Doncaster and Bassetlaw Teaching Hospitals NHS Foundation TrustStated in progressThe respondent said that this action was in progress when they made their response on 3 August 2021.
Action
Develop and implement electronic paediatric observations, incorporating sepsis screening into Nervecentre after deployment.
Stated by Doncaster and Bassetlaw Teaching Hospitals NHS Foundation TrustStated plannedThe respondent said that this action was planned when they made their response on 3 August 2021.
Action
Continue mandatory induction and multidisciplinary staff-development training on paediatric sepsis recognition, management and use of the screening tool.
Stated by Doncaster and Bassetlaw Teaching Hospitals NHS Foundation TrustStated in progressThe respondent said that this action was in progress when they made their response on 3 August 2021.
Action
Include recognition and management of the sick child, including sepsis screening, in Emergency Department junior-doctor induction.
Stated by Doncaster and Bassetlaw Teaching Hospitals NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 3 August 2021.
Action
Deliver recurring Emergency Department teaching sessions on sepsis recognition, management and use of the sepsis screening tool.
Stated by Doncaster and Bassetlaw Teaching Hospitals NHS Foundation TrustStated in progressThe respondent said that this action was in progress when they made their response on 3 August 2021.
Action
Run weekly multidisciplinary paediatric simulation sessions across both sites, including paediatric sepsis topics.
Stated by Doncaster and Bassetlaw Teaching Hospitals NHS Foundation TrustStated in progressThe respondent said that this action was in progress when they made their response on 3 August 2021.
Action
Employ a Paediatric Clinical Educator for Emergency Department staff induction and sepsis-screening support.
Stated by Doncaster and Bassetlaw Teaching Hospitals NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 3 August 2021.
Action
Incorporate sepsis screening into the Emergency Department Symphony system and train staff before implementation.
Stated by Doncaster and Bassetlaw Teaching Hospitals NHS Foundation TrustStated in progressThe respondent said that this action was in progress when they made their response on 3 August 2021.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1
Position
Immediate sepsis treatment with clear documentation makes retrospective completion of the sepsis screening tool unnecessary.
Stated by Doncaster and Bassetlaw Teaching Hospitals NHS Foundation TrustDisputes the concernThe respondent disagreed with part of the concern or the basis for it.
Avon
Concerns raised1
Lack of sepsis awareness in schools
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 departmental health and safety guidance for schools to reference the OEAP’s sepsis-awareness guidance.
Stated by Rt Hon Gavin Williamson CBE MPStated plannedThe respondent said that this action was planned when they made their response on 28 June 2021.
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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.
