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We need a review of all sepsis deaths, not the conviction of health professionals, to improve the care of patients with sepsis

Dr Paul Morgan and I discuss deaths from sepsis in a letter published in the British Medical Journal. NHS England estimates that approximately 37 000 deaths a year are caused by sepsis.[1] This means that in the seven year period between 2011 and 2017, around 259 000 people died from sepsis in England. Only one of these deaths, that of Jack Adcock in Leicester in 2011, has resulted in the conviction of health professionals for manslaughter (Hadiza Bawa-Garba and Isabel Amaro).[2]

Sepsis can be difficult to diagnose, and delays and omissions in its diagnosis and treatment contribute to the high death rate. Even the former chair of the General Medical Council, Graham Catto, has admitted that he failed to diagnose sepsis in a timely manner, an error that contributed to a patient’s death.[3] Because of the problems diagnosing and treating sepsis, numerous initiatives have aimed to improve its management in both primary care and hospital settings. Details of one of the most recent of these initiatives were published by NHS England in September 2017.[4]

Given the scale of death from sepsis and the many delays and errors so often seen in its management, why were Bawa-Garba and Amaro convicted of gross negligence manslaughter? Was their management of Jack Adcock so different from the management of other cases of sepsis that resulted in death that they were justly convicted? Or were they involved in just one of many cases where suboptimal management of sepsis contributed to death? NICE guidance NG51 and Quality Standards QS161 have only recently set out the expectations of best practice in sepsis care—several years after Bawa-Garba and Amaro were charged.[5,6]

We need an objective review of sepsis deaths to identify the contribution of suboptimal management to the death and to recognise lessons for the future in a non-judgmental manner, not the prosecution of health professionals, if we are to improve clinical outcomes for patients with sepsis.

References
1. NHS England. Improving outcomes for patients with sepsis A cross system action plan. December 2015. https://www.england.nhs.uk/wp-content/uploads/2015/08/Sepsis-Action-Plan-23.12.15-v1.pdf
2. Ladher N, Godlee F. Criminalising doctors. BMJ2018;360:k479.doi:doi:10.1136/bmj.k479pmid:29419388
3. NHS National Patient Safety Agency. Medical Error. August 2005. http://www.nrls.npsa.nhs.uk/resources/?EntryId45=61579
4. NHS England. Sepsis guidance implementation advice for adults. September 2017. https://www.england.nhs.uk/publication/sepsis-guidance-implementation-advice-for-adults/
5. National Institute for Health and Care Excellence. Sepsis: recognition, diagnosis and early management. NICE guidance NG51. July 2016. https://www.nice.org.uk/guidance/ng51
6. National Institute for Health and Care Excellence. Sepsis. Quality Standard 161. September 2017. https://www.nice.org.uk/guidance/qs161

DOI: https://doi.org/10.1136/bmj.k629

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