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 follow NICE sepsis risk stratification guidance for lactate levels above 2
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.1
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Action
Update the MKUH sepsis policy at its scheduled November 2021 review.
Stated by Milton Keynes University Hospital NHS Foundation Trust
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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Position
The patient was not suspected of sepsis and lacked high-risk criteria, so guidelines did not mandate repeat lactate measurement or imply likely clinical benefit.
Stated by Milton Keynes University Hospital NHS Foundation Trust
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Concerns raised2
Outdated guidance and protocols for recognition of sepsis
Lack of mandatory sepsis training
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.
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
Continue working with NHS Trusts to design policies and best practice for improving sepsis diagnosis and management.
Stated by Department of Health and Social Care
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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Position
Whether sepsis training should be mandatory is an employer decision, rather than a matter determined by the responding body.
Stated by Department of Health and Social Care
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Concerns raised1
Failure by treating clinicians to recognise and record activation of the septic shock pathway
This report raised 16 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
National pathfinder tool failing to clearly direct immediate expedited hospital transfer for sepsis
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 concernsEach statement is shown once, even when linked to more than one concern.
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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Position
The choice of clinical triage tool remains the responsibility of individual ambulance services rather than being mandated nationally.
Stated by Department of Health and Social Care
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Position
No Pathfinder changes are considered necessary because the tool remains a safe and effective assessment and triage tool.
Stated by Department of Health and Social Care
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Concerns raised1
Failure to recognise the adverse effects of sepsis when they occur
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 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
Provide ongoing Sepsis training on the Sepsis 6 bundle and NEWS documentation, escalation and implementation to medical and nursing staff.
Stated by Cwm Taf Morgannwg University Local Health Board -
Action
Introduce point-of-care venous blood-gas testing to identify abnormal lactate results for early sepsis identification.
Stated by Cwm Taf Morgannwg University Local Health Board
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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Position
Further sepsis training for medical and nursing staff is currently paused because of COVID-19 activity.
Stated by Cwm Taf Morgannwg University Local Health Board
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Concerns raised2
Gaps in agency nurse training and understanding of septic screening procedures
Failure to use and record clear, continuing sepsis terminology in suspected sepsis patients
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 raised1
Unavailability of intravenous antibiotic administration by ambulance paramedics when emergency department admission is delayed
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 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
Conduct the PhRASe feasibility study, including paramedic screening, randomisation, blood-culture collection and intravenous antibiotic administration, and complete anonymised follow-up analysis.
Stated by Welsh Ambulance Services NHS Trust
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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Position
The Trust will not provide routine pre-hospital antibiotics because evidence, training, equipment, costs and antimicrobial-resistance concerns constrain implementation.
Stated by Welsh Ambulance Services NHS Trust
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Position
Health Board Emergency Department staff are responsible for initiating antibiotics for patients delayed in ambulances because they prescribe and select appropriate treatment.
Stated by Welsh Ambulance Services NHS Trust
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Concerns raised1
Failure to recognise early signs of sepsis and clinical deterioration in the NICU
This report raised 8 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 of the free text box to generate automatic red flags from identified symptoms
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.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.3
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Position
NHS Digital is responsible for delivering NHS Pathways and its Directory of Service clinical decision tool.
Stated by NHS England
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Position
NHS Digital’s separate response is considered to cover and answer all specific NHS Pathways recommendations.
Stated by NHS England -
Position
Free-text analysis cannot safely be introduced because sufficient expertise and evidence do not currently exist; developing technology remains under review.
Stated by NHS England
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Concerns raised3
Unclear staff instructions for Emergency Department management of patients with symptoms suggestive of sepsis
Failure to correctly diagnose and treat patients with suspected sepsis
Failure to carry out required tests for patients with symptoms suggestive 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.
Data last updated 7 September 2026