Sepsis – greater awareness can lead to better outcomes

In September, I attended the Brain Injury Group’s Sepsis training event in the City of London with my colleague, Gemma Salmon.

Throughout the day, we heard from several distinguished speakers with experience identifying and treating Sepsis in the community and a hospital setting. We also learnt about the catastrophic and often fatal consequences of a delay in diagnosing Sepsis.

As medical negligence lawyers, we were particularly interested to hear about the steps responsible medical practitioners should take to identify Sepsis as early as possible and learn about how early identification and treatment can lead to better outcomes.

Diagnosing Sepsis

There is no accepted definition of sepsis, and the definitions used have changed many times over the years. However, Professor Klein of Great Ormond Street Hospital gave the most useful definition, and one which is most commonly used nowadays, as follows:

“Sepsis is an acute, non-specific, generalised, whole body, inflammatory response to infection”

It was interesting to learn that the infection itself is not the problem in patients with Sepsis (although the source of the infection does need to be controlled), but rather the body’s response to such infection. In the most severe cases, the body’s response can lead to multi-organ failure and even death.

Diagnosing Sepsis early on can be extremely difficult. Many of the symptoms patients present with are similar to other frequently encountered conditions such as the common cold, particularly within the first four to six hours. It is GPs who are often the first port of call for sick people, and there are a number of steps that GPs should be taking in order to make sure that they do not miss a diagnosis of Sepsis. Firstly, Dr Mike Ingram informed us that GPs should be taking, and recording, observations from their patients. A common sign of a patient suffering from Sepsis is a raised respiratory rate. Whilst observations alone will not enable the GP to arrive at a diagnosis, ensuring that they are recorded, and comparing the most recent observations with previous ones, will enable a GP to spot any deterioration in the patient’s condition and to act accordingly.

Dr Ingram informed us that the average-sized GP practice will see only one case of Sepsis in a patient per year. The challenge for each GP is identifying that patient; often, the “gut feeling” that something is wrong is the most powerful predictor. However, there are also tools that a GP can use to help them make, or rule out, a Sepsis diagnosis. For example, the Sepsis Trust has developed guidance for GPs. Dr Ingram identified a number of risks that GPs will fail to diagnose Sepsis, which could lead them exposed to a future Clinical Negligence claim:

1. Failing to record, or react to, vital signs – such as blood pressure, pulse, respiratory rates, temperature and oxygen saturation. GPs should record vital signs in writing, and relate these to each other, in order to spot any red flags.
2. Diagnosing diarrhoea and vomiting as gastroenteritis – GPs often fall back on this diagnosis. Still, they should consider whether they can justify this diagnosis, and make sure that they are able to rule out Sepsis. It is better to say so if they are unsure, rather than take the risk.
3. Loss of continuity of care – often patients will return to the GP practice if their symptoms do not improve, but more commonly now will not be seen by the same person. The risk here is that the GP does now know the patient. Changes to GP’s working structures make this risk much more likely. If the GP does not know the patient, picking up on uncharacteristic behaviour will be much harder.
4. Not listening to the patient – Dr Ingram pointed out that listening to the patient is one of the most important things a GP can do. If the patient is telling the GP they have never felt this unwell before (which will often be the case in patients with Sepsis), then this should be a red flag and further investigation undertaken.
5. Telephone advice – this is not as reliable as seeing the patient in consultation in person. It is easier to spot a severely unwell person in the flesh, than it is by speaking to them over the telephone. If a GP suspects a patient is becoming severely unwell, they should insist the patient come into the surgery.
6. False diagnosis – similar to point 2 above, a GP should not make a diagnosis unless they are almost certain. It is important to ‘safety net’ the patient, telling them to return or attend A&E if their condition deteriorates. GPs should always bear in mind the expectation of the diagnosis they reach, and should take the appropriate action if the course of events does not follow what is expected (it could be Sepsis).

From a Claimant lawyer’s perspective and in light of the above, the client’s medical notes should be closely scrutinised to identify instances where a GP’s care can be said to have fallen below what can be reasonably expected.

The Effects of Sepsis

Following the talk from Dr Ingram, we listened to a useful presentation on causation in Sepsis cases from Dr James Stone, Consultant Medical Microbiologist.

Dr Stone clarified that Sepsis is a dynamic condition, with the progression being much more complex than simply inflammation or microbial replication. Sepsis can have a negative effect on a range of tissues and organs, and the progression will accelerate over time, again highlighting the vital importance of a timely diagnosis.

However, whilst early treatment in the form of antibiotics and fluids is the most effective and leads to the best outcomes, Dr Stone was keen to point out that treatment late on can still positively effect outcomes for patients. One common causation argument used by Defendants in Clinical Negligence cases is that the condition was too far advanced for any medical intervention to have been effective.

US guidelines state:

“we recommend that administration of IV anti-microbials be initiated as soon as possible after recognition and within one hour for both sepsis and septic shock”.

With increasing delays in antimicrobial medication being administered, you also get increased morbidity and so there are long term effects as well as short term effects, the chance of which are increased by delay.

But, timing is of crucial significance in Sepsis cases and it is often possible to show that if intervention would have happened earlier than it did, outcomes would have been better for the patient .

Dr Stone said that it is helpful for lawyers to consider the timelines of events, both the infecting organism and the host response. In respect of the infecting organism, the innoculation time (entering the body), lag phase (where the bacteria acclimatises to the new environment), and the log phase (accelerating bacterial growth, enzyme and toxin production) should all be considered, with the help of expert medical evidence. Further, in respect of the host response, expert evidence should consider the innate inflammatory response (which will differ between patients), positive feedback leading to an exponential rise in toxic substances, collateral damage in the host tissues, and the overshoot of the inflammatory response which leads to further collateral damage to the host. In patients who present at hospital already in Septic shock, creating the timeline of events can be extremely difficult.

Dr Stone highlighted some common causation arguments he has encountered from Defendant lawyers:

1. Late presentation – sepsis could have been established and prolonged at the time of first presentation to medical professionals. Defendants may argue that even if there has been a breach of duty, the outcome would have been the same.
2. Multiple previous and current co-morbid conditions – Defendants may argue that such conditions make survival of Sepsis unlikely, even with optimal therapy.
3. Infection with very unusual, multi-resistant bacterium – Defendants will argue that in these cases, an initial inappropriate choice of antibiotic may be made by treating professionals, albeit unavoidably. As a result, there could be an unavoidable delay in commencing effective drug treatment.

In light of all of the above, and perhaps worryingly for claimant lawyers, Dr Stone observed that determining causation following any breach of duty can be extremely difficult in Sepsis cases, particularly those with non-fatal outcomes.

Post-Sepsis Care

Almost all patients suffering from Sepsis will spend time in Intensive Care, and later in the afternoon, Dr Carl Waldmann, an Intensive Care Consultant at Royal Berkshire Hospital, gave an interesting talk. He spoke about how intensive care is now a specialised area, which used to be the reserve of anaesthetists.

Patients will be admitted to an ICU where they are in need of organ support (for example, a ventilator, kidney machine, or blood pressure drugs). Being in ICU is often a very distressing time for patients and their families, both physically and emotionally. Dr Waldmann’s main point was that when patients leave intensive care, they must receive rehabilitation.

The importance of that point is reflected in the fact that NICE Guidelines now mandate rehabilitation and a plan for such rehabilitation for every patient leaving ICU. In patients who have suffered from Sepsis, there is a high incidence of long-term complications, so intensive care units should now focus on quality of life and rehabilitation.

Worryingly, Dr Waldmann said there is a huge gap in society in the provision of rehabilitation, which led him to set up the ICU follow-up clinic in Reading. He reported that some other hospitals have followed his lead in setting up such clinics, which focus on supporting patients on the road to recovery following their discharge from ICU.

What became clear from my perspective, as a clinical negligence lawyer following all of these interesting talks – the complexity of Sepsis cases, and the importance of looking closely at the timeline of events in each case to determine whether things could have been done differently.

Additionally, whilst early treatment and a stay on the ICU ward are vitally important in ensuring that a patient makes the best possible recovery from Sepsis, lawyers should also be paying close attention to ensuring that their client is appropriately followed up after their discharge from ICU so that they can receive the appropriate rehabilitation and make the best possible recovery. Claimant and Defendant lawyers have incentives to ensure this is the case.

Sepsis Trust

One of the final talks of the afternoon was given by Liz Truss, a survivor of Sepsis and a volunteer for the Sepsis Trust, which exists to raise awareness of Sepsis. Liz gave the frightening statistic that over 40,000 people die as a result of Sepsis every year in the UK, and stressed the importance of always asking the question to medical professionals if you or a loved one suddenly becomes very unwell, “could it be Sepsis”.

Medical negligence sepsis case study

Jodi Newton, Solicitor in our surgical negligence team, settled a claim earlier this month for her client, who suffered a very serious episode of sepsis and was hospitalised for over two months. He has been left with permanent neurological injuries.

Our client underwent chest surgery to remove a foreign body which had previously caused infection and to treat chronic inflammatory change. It was thought the foreign body may have been a filling which our client had inadvertently swallowed. Our client was swabbed to check for the possibility of infection. The swab was mislabelled with the name of a different patient and our client’s swab, which showed a serious infection but went unnoticed due to the mislabelling.

Our client was discharged from Hammersmith Hospital shortly after the surgery.

Six days later, he was admitted as an emergency patient, initially diagnosed with pneumonia. He continued to deteriorate and a CT scan showed a significant collapse in his chest. Furthermore, the metal object was shown as still present in radiology. A brain MRI scan taken after his admission showed multiple enhancing lesions and associated white-matter oedema, interpreted as being consistent with septic embolic phenomena, which is a highly dangerous condition and, if left any longer, could have proven fatal.

He had suffered a serious sepsis infection and was an inpatient for over two months. He required extensive rehabilitation. If the swab had been appropriately labelled, he would not have been discharged, particularly as his CRP levels (a simple blood test showing infection) had significantly increased the day before discharge. This should have alerted the surgical team to the likelihood of ongoing infection in the lung because it was likely that not all of the foreign body had been removed. His treatment pathway would have been by intravenous antibiotics for 24-48 hours, followed by oral antibiotics and importantly, he would have avoided sepsis and permanent neurological injuries.

The infection identified on the operative swab was the source of the Claimant’s infection, which had reached his heart and caused brain abscesses. Suitable treatment would have avoided those serious complications.

Making a sepsis claim

Our client initially complained to the hospital; however, his complaint was generally rebuffed and he felt he had no alternative but to instruct solicitors. We obtained evidence from a cardio-thoracic surgeon, a microbiologist and a neurologist, who were all supportive of the claim. After we served a Letter of Claim, the Trust denied liability and we therefore served court proceedings, which were also defended.

We made an offer to settle this case. However, the Defendant responded by inviting our client to discontinue his case. About six months later, however, the case was successfully settled for a sum of £70,000 even though the Defendant continued to maintain its denial of liability.”

Figures from The UK Sepsis Trust highlight that five people die from Sepsis every hour in the UK, and 40% of survivors are left with life-changing effects. For more information on how to spot the symptoms of sepsis, please visit their website.

If you believe you have suffered an injury due to poor medical care, contact Jodi Newton or another member of our medical negligence team. We will be happy to have a confidential conversation with you and advise you of any next steps.

Blog by Nicholas Leahy.