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Time to Act: Severe sepsis - rapid diagnosis and treatment saves lives

Appendix 1 - Standards of care

The Ombudsman’s role was set up by Parliament nearly 50 years ago to help individuals and the general public.

We are not part of government or the NHS: our role is to investigate complaints that individuals have been treated unfairly or have received poor service from government departments and other public organisations, and the NHS in England.  We ask people to complain to the organisation they are unhappy about before bringing their complaint to us. 

Our powers are set out in law and the service is free for everyone.  The law gives us the power to investigate individual complaints, and to produce a report on our findings that recommends how mistakes can be put right.  If the investigations find big or repeated mistakes, we share this information with regulators to help them do their job.

We share information about our work with Parliament to help them hold government and the NHS in England to account for the service those organisations provide and the way they handle complaints.

We are empowered to investigate complaints about the NHS in England by virtue of the Health Service Commissioners Act 1993.  In general terms, when determining complaints we begin by comparing what actually happened with what should have happened.  To do so, we seek to establish a clear understanding of the evidence, and of the standards that applied at the time the events complained about occurred.

We usually take advice from clinical advisers, who are independent of the organisations complained about, in order to better understand the clinical aspects of a complaint. Specifically, we assess whether or not an act or omission on the part of the organisation or individual complained about constitutes a departure from the applicable standard.  If so, we then assess whether, in all the circumstances, those acts or omissions fell so far short of the applicable standard that they constituted service failure.  

If we find that service failure has resulted in an injustice, we will uphold the complaint.

General standards of care

The NHS Constitution (published 2009, updated 2012) states: 

  • ‘[Patients] have the right to be treated with a professional standard of care, by appropriately qualified and experienced staff in a properly approved or registered organisation that meets required levels of safety and quality.'  
  • ‘[Staff] have a duty to accept professional accountability and maintain the standards of professional practice as set by the appropriate regulatory body.

Professional standards

The GMC guidance for doctors Good Medical Practice (2006) includes:

  • Good doctors must keep their knowledge and skills up to date.
  • Good clinical care must include: adequately assessing the patient’s condition, providing or arranging advice, investigations or treatment where necessary and referring to another practitioner when this is appropriate.

The Nursing and Midwifery Council’s The code: Standards of conduct, performance and ethics for nurses and midwives (the NMC Code of Conduct) (2008):

  • ‘[The NMC Code of Conduct] is the foundation of good nursing and midwifery practice and is a key tool in safeguarding the health and well-being of the public.'
  • ‘[Nurses] are personally accountable for actions and omissions in [their] practice and must always be able to justify [their] decisions.’

Clinical standards

A number of organisations have published guidance on the essentials of recognition, general care, monitoring and treatment of the acutely and/or critically ill patient. 
These include:

The Royal College of Surgeons has published two reports recently on the specific challenges faced in the provision of quality care for those needing emergency and high-risk surgery (2011).  Points emphasised in these reports include the need to afford priority to the acutely ill; the timely input of senior decision makers; the importance of prompt recognition and treatment; and the immediate care of severe sepsis.  Their reports can be found at: www.rcseng.ac.uk/publications

The Royal College of Obstetricians and Gynaecologists has similarly addressed the issues specifically relating to maternity, where sepsis is now the most common cause of mortality related to childbirth: 

Hospitals cannot function effectively without adequate staff, infrastructure, support, organisation, and management. The Society for Acute Medicine has published a helpful Quality Standards for Acute Medical Units, available at: www.acutemedicine.org.uk

In Scotland, there have been recent helpful educational initiatives with similar learning messages.

Standards for the management of acute sepsis

The Surviving Sepsis Campaign is an international collaboration of clinical specialists.  It has produced very detailed, evidence-based guidance, published most recently as:

Care bundles – groups of interventions that, when implemented together, achieve better outcomes than if implemented singly – have been derived from the Surviving Sepsis Campaign and are available online at:  www.survivingsepsis.org

The UK Sepsis Trust has summarised the key tasks for immediate care – the ‘sepsis six’.  These are:

  1. give high-flow oxygen
  2. take blood cultures
  3. give intravenous antibiotics
  4. start intravenous fluid resuscitation
  5. check haemoglobin and lactate
  6. monitor accurate hourly urine output.

Summary

In the investigation of complaints in which the central issue is the clinical management of severe sepsis, our advisers and caseworkers draw these various standards and guidelines together in a way that can be summarised as follows:

For the provision of clinical care:

  • Timely history and examination on admission or referral.
  • Investigations to determine:

Indices of perfusion

Indices of infection

Source of infection

  • Cultures of blood and other sites.
  • Regular physiological monitoring using track and trigger systems.
  • Accurate recognition of the severity of the illness.
  • Basic resuscitation with: 

Large-volume fluid therapy (at least 30ml/kg challenge initially)

Intravenous broad-spectrum antibiotics after taking cultures

Oxygen

Vasopressor therapy if required to maintain adequate circulation.

  • All of this to commence immediately on recognition of severe sepsis and to be completed within six hours of presentation.
  • Source control (drainage of infected fluid collections) to be performed as soon as possible after initial resuscitation.

For the organisation of care:

  • Adequate education and training of staff.
  • Appropriate and timely senior medical input.
  • Timely referral to critical care.
  • Formation and documentation of a management plan.
  • Protocol for handover.
  • Appropriate and timely referral for source control.
  • Availability of appropriate drugs, equipment and diagnostic facilities at all times in acute hospitals receiving emergency patients.

Each case story described in this report includes a table of the shortcomings we identified, based on the standards in this summary.