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 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.
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.1
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Position
NHS Pathways already considers sepsis through symptom-based assessment and provides an option to identify suspected sepsis.
Stated by NHS England
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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.
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.3
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Action
Deliver a QEHB Emergency Department sepsis training programme with staff champions, educational events, safety-board information and ongoing staff education.
Stated by University Hospitals Birmingham NHS Foundation Trust -
Action
Embed sepsis screening in Rapid Assessment and Triage to support recognition across the spectrum of presentation.
Stated by University Hospitals Birmingham NHS Foundation Trust -
Action
Continue working with NHS England to identify resources needed for healthcare professionals to recognise and respond appropriately to patient deterioration.
Stated by Department of Health and Social Care
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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.
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.4
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Action
Recruit a Sepsis Lead Nurse responsible for Trust-wide compliance with the Sepsis 6 protocol.
Stated by The Trust -
Action
Work towards 100% compliance with Sepsis training across all clinical areas.
Stated by The Trust -
Action
Work towards including Sepsis training in mandatory training for clinical staff, with later extension to non-clinical staff.
Stated by The Trust
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Action
Continue cyclical Sepsis audits and improvement programmes.
Stated by The Trust
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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.
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.4
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Action
Work with stakeholders to raise awareness among families and carers about sepsis signs, including how signs may appear on darker skin.
Stated by NHS England -
Action
Review whether to add images or videos to the NHS sepsis page to support recognition of visible symptoms.
Stated by NHS England -
Action
Update NHS Down’s syndrome information to clarify increased susceptibility to infection and consequences.
Stated by NHS England
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Action
Update NHS sepsis guidance to identify genetic disorders, including Down’s syndrome, as increasing sepsis risk.
Stated by NHS England
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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.
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
Deliver focused training on atypical sepsis presentation and maintaining a high index of suspicion, particularly with high lactate, in high-prevalence clinical areas.
Stated by Royal Berkshire NHS Foundation Trust
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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.
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.5
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Action
Use a mandatory electronic sepsis-suspicion field that triggers the sepsis pathway and captures compliance data.
Stated by Barking, Havering and Redbridge University Hospitals NHS Trust -
Action
Audit electronic sepsis-suspicion documentation monthly and report compliance through established assurance arrangements.
Stated by Barking, Havering and Redbridge University Hospitals NHS Trust -
Action
Update the Trust sepsis education programme and provide additional face-to-face training for doctors and nurses.
Stated by Barking, Havering and Redbridge University Hospitals NHS Trust
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Action
Adopt the UK Sepsis Trust adult screening tool and audit its use, high-risk patients and positive blood-culture compliance with the Sepsis 6.
Stated by Barking, Havering and Redbridge University Hospitals NHS Trust -
Action
Provide regular weekly sepsis teaching sessions in Acute Medicine across both sites.
Stated by Barking, Havering and Redbridge University Hospitals NHS Trust
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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.
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 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.
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 combined maternal sepsis guideline to include timely identification and treatment guidance for herpes simplex, scheduled for publication in March 2024.
Stated by Royal College of Obstetricians and Gynaecologists
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
National guidance on diagnosing and treating pregnancy-related sepsis and antiviral prescribing is outside the organisation’s remit.
Stated by NHS England
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Position
Responsibility for relevant national sepsis guidance lies with the Royal College of Obstetricians and Gynaecologists.
Stated by NHS England
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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.
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 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.
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