Recurring concern
Failure to reliably recognise and respond promptly to sepsis
- 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.
Trends
Reports over time
Reports mentioning this concern, 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.
Reports and published responses 52 reports
See individual reports that have raised this concern, and the actions taken in response
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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.
Linked response
- Milton Keynes University Hospital NHS Foundation Trust
Stated actions 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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Milton Keynes University Hospital NHS Foundation Trust
Update the MKUH sepsis policy at its scheduled November 2021 review.
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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Milton Keynes University Hospital NHS Foundation Trust
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.
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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.
Linked response
- Department of Health and Social Care
Stated actions An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.1
-
Department of Health and Social Care
Continue working with NHS Trusts to design policies and best practice for improving sepsis diagnosis and management.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1
-
Department of Health and Social Care
Whether sepsis training should be mandatory is an employer decision, rather than a matter determined by the responding body.
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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.
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.
Linked response
- 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.2
-
Department of Health and Social Care
The choice of clinical triage tool remains the responsibility of individual ambulance services rather than being mandated nationally.
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Department of Health and Social Care
No Pathfinder changes are considered necessary because the tool remains a safe and effective assessment and triage tool.
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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.
Linked response
- Cwm Taf Morgannwg University Local Health Board
Stated actions 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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Cwm Taf Morgannwg University Local Health Board
Provide ongoing Sepsis training on the Sepsis 6 bundle and NEWS documentation, escalation and implementation to medical and nursing staff.
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Cwm Taf Morgannwg University Local Health Board
Introduce point-of-care venous blood-gas testing to identify abnormal lactate results for early sepsis identification.
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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Cwm Taf Morgannwg University Local Health Board
Further sepsis training for medical and nursing staff is currently paused because of COVID-19 activity.
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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.
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.
Linked response
- Welsh Ambulance Services NHS Trust
Stated actions 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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Welsh Ambulance Services NHS Trust
Conduct the PhRASe feasibility study, including paramedic screening, randomisation, blood-culture collection and intravenous antibiotic administration, and complete anonymised follow-up analysis.
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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Welsh Ambulance Services NHS Trust
The Trust will not provide routine pre-hospital antibiotics because evidence, training, equipment, costs and antimicrobial-resistance concerns constrain implementation.
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Welsh Ambulance Services NHS Trust
Health Board Emergency Department staff are responsible for initiating antibiotics for patients delayed in ambulances because they prescribe and select appropriate treatment.
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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.
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.
Linked response
- NHS England
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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NHS England
NHS Digital is responsible for delivering NHS Pathways and its Directory of Service clinical decision tool.
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NHS England
NHS Digital’s separate response is considered to cover and answer all specific NHS Pathways recommendations.
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NHS England
Free-text analysis cannot safely be introduced because sufficient expertise and evidence do not currently exist; developing technology remains under review.
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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.
No linked response statementsNo respondent-stated action or position is linked to these concerns in the published data.
Actions and positions describe what organisations say in published responses. Implementation is not independently verified.
Data last updated 7 September 2026