Annette HILL · Prevention of Future Deaths report

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Issued 21 Sep 2018•Avon

Published report and response evidence

This report’s concerns and statements found in recipients’ published responses. Statements are included even where no link to an individual concern is recorded. A link shows an evidence connection; it does not assign responsibility.

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Concerns
1

Raised in this report

Recipients
1

Named on the report

Responses found
1

Of 1 recipient

Stated actions
2

Described in responses

Recipients and published responses

Full report text

This is the full text from the original published report.

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Concerns and recipient responses

Select any concern, action or position to view the source wording.

Concerns raised1

  1. Unresolved tension between Sepsis 6 guidelines and the BTS COPD care bundle

Stated actions An action is something a recipient says it has done, is doing, or plans to do in response to a concern raised.2

  1. Bristol NHS Foundation Trust

    Implement the Sepsis Six guidelines for every patient attending the emergency department, prioritising them before the COPD care bundle.

  2. Bristol NHS Foundation Trust

    Review the potential conflict between the Sepsis Six pathway and COPD care bundle through the Sepsis Group.

Respondent positions A position is what a recipient says about a concern when it does not describe a specific action.2

  1. Bristol NHS Foundation Trust

    The Sepsis Six pathway and BTS COPD care bundle do not conflict for patients with exacerbated COPD.

    Disputes the concernThe respondent disagreed with part of the concern or the basis for it.
  2. Bristol NHS Foundation Trust

    The current sepsis approach, including senior clinical review before antibiotics, is considered sufficient and does not need to change.

    Existing arrangements considered sufficientThe respondent said that existing arrangements were sufficient, so no further action was needed.

Source evidence

How this individual concern was interpreted

PFD Monitor created a concise, searchable interpretation from the report wording shown below. Response links show a clear evidence connection; they do not assign responsibility.

PFD Monitor interpretation

Unresolved tension between Sepsis 6 guidelines and the BTS COPD care bundle

Wider context from the report

“(1) This patient received IV antibiotics correctly in accordance with the Sepsis 6 guidelines. However, she did not in fact require antibiotics on an overview of the available information. There appears to be an unresolved tension between the Sepsis 6 guidelines and the BTS COPD care bundle for the management of patients with advanced respiratory disease. ”

Is this part of a recurring concern?

No recurring-concern membership is currently published.

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Source evidence

How this respondent action was interpreted

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

PFD Monitor interpretation

Implement the Sepsis Six guidelines for every patient attending the emergency department, prioritising them before the COPD care bundle.

Verbatim wording from the response

“The need for time critical preventative treatment against suspected sepsis means that the Sepsis Six guidelines are implemented immediately and each patient’s risk of sepsis is considered once they attend the ED.”

Source location

Response from North Bristol NHS Trust
Page 3 · response
Published 6 November 2024

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Source evidence

How this respondent action was interpreted

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

PFD Monitor interpretation

Review the potential conflict between the Sepsis Six pathway and COPD care bundle through the Sepsis Group.

Verbatim wording from the response

“The RCA identified the possible conflict between the British Thoracic Society COPD care bundle and the Sepsis 6 guidelines in relation to the prescription of antibiotics in patients with undiagnosed exacerbation of airways disease. It was recommended that the potential conflict be reviewed at the Sepsis Group meeting. This group convened on 16 October 2018 and was of the opinion there was no conflict with the COPD care bundle. Furthermore they did not feel that the Trust’s current approach to sepsis needed to change. They highlighted that there will always be patients who overlap clinical guidelines (sometimes several) and it is important to recognise the guidelines are there to assist clinicians, but clinical judgment must always be used which is why a senior clinician reviews each patient before antibiotics are administered to those at risk of sepsis.”

Source location

Response from North Bristol NHS Trust
Page 3 · response
Published 6 November 2024

Open published response

Source evidence

How this respondent position was interpreted

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

PFD Monitor interpretation

The Sepsis Six pathway and BTS COPD care bundle do not conflict for patients with exacerbated COPD.

Verbatim wording from the response

“The RCA identified the possible conflict between the British Thoracic Society COPD care bundle and the Sepsis 6 guidelines in relation to the prescription of antibiotics in patients with undiagnosed exacerbation of airways disease. It was recommended that the potential conflict be reviewed at the Sepsis Group meeting. This group convened on 16 October 2018 and was of the opinion there was no conflict with the COPD care bundle. Furthermore they did not feel that the Trust’s current approach to sepsis needed to change. They highlighted that there will always be patients who overlap clinical guidelines (sometimes several) and it is important to recognise the guidelines are there to assist clinicians, but clinical judgment must always be used which is why a senior clinician reviews each patient before antibiotics are administered to those at risk of sepsis.”

Source location

Response from North Bristol NHS Trust
Page 3 · response
Published 6 November 2024

Open published response

Source evidence

How this respondent position was interpreted

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

PFD Monitor interpretation

The current sepsis approach, including senior clinical review before antibiotics, is considered sufficient and does not need to change.

Verbatim wording from the response

“The RCA identified the possible conflict between the British Thoracic Society COPD care bundle and the Sepsis 6 guidelines in relation to the prescription of antibiotics in patients with undiagnosed exacerbation of airways disease. It was recommended that the potential conflict be reviewed at the Sepsis Group meeting. This group convened on 16 October 2018 and was of the opinion there was no conflict with the COPD care bundle. Furthermore they did not feel that the Trust’s current approach to sepsis needed to change. They highlighted that there will always be patients who overlap clinical guidelines (sometimes several) and it is important to recognise the guidelines are there to assist clinicians, but clinical judgment must always be used which is why a senior clinician reviews each patient before antibiotics are administered to those at risk of sepsis.”

Source location

Response from North Bristol NHS Trust
Page 3 · response
Published 6 November 2024

Open published response
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Information checked against the published report and official responses · Data reviewed 7 Sep 2026 · About data quality and limitations

Data last updated 7 September 2026