An urgent diagnosis

ONE-YEAR-OLD William had not been well for weeks – suffering from a recurring chest infection with coughing, fever and vomiting. On a Friday his nursery called home to say that he had a persistent temperature despite having been given liquid paracetamol. An emergency appointment was arranged at his GP surgery and William’s father took him along.

A GP examined William and found him febrile and congested, a bit quiet but otherwise he was “alert and engaging”. The usual safety netting advice was given and when William’s father asked at what point the child should be brought back in he was reassured that it was “nothing grisly”.

That night William was off his food and the next day he remained unwell and was vomiting. His mother phoned NHS 111 that evening for advice and she later spoke to a doctor on call who took a history over the phone and asked if William’s mother would like to bring him in to the out-of-hours clinic. But by this time the boy was sleeping. Asked his professional opinion, the doctor said he thought it best to leave him be for now.

His parents went to bed at 10.30pm that night and William’s father recalled him moving around 5am but when his mother went to wake the child at 8.30 she discovered William was not breathing. An ambulance was called but the child was pronounced dead at 8.47am.

An inquest later found that William had died from septicaemia caused by a long-standing chest infection and pneumonia. It emerged that his mother had taken her son to the GP numerous times in the weeks leading up to his death.

A recent NHS England report on William’s case has highlighted the need for better recognition of sepsis among healthcare professionals and recent guidance from NICE is now recommending that patients showing signs of sepsis should be treated with the same urgency as those with suspected heart attacks.

The NHS England report into William’s death concluded that critical opportunities were missed that might have saved his life. It found that GPs had not recorded vital clinical details, the out-of-hours GP service did not have access to William’s primary care records and, crucially, the pathway tool used by NHS 111 advisers had been too crude to pick up “red-flag” warnings relating to sepsis.

Sepsis is a clinical syndrome caused by the body’s immune and coagulation systems being switched on by an infection and going into overdrive. Sepsis with shock is a life-threatening condition characterised by low blood pressure despite adequate fluid replacement, and organ dysfunction or failure.

The UK Sepsis Trust estimates that there are around 150,000 cases of sepsis in the UK every year and it kills around 44,000 people. Quick identification and early treatment are key to avoid death or lasting morbidity, yet a report published last year revealed that in over a third (36 per cent) of cases there were delays in identifying sepsis. The National Confidential Enquiry into Patient Outcome and Death found that many hospitals had no formal protocols in place to recognise sepsis.

Professor Saul Faust from the University of Southampton, who chaired the group that developed the NICE guidelines, said: “Anyone can succumb to sepsis. It can come on as the result of a minor injury or infection that the body is trying to recover from and the immune system goes into overdrive. Sepsis can be difficult to diagnose with certainty.”

Symptoms may vary from person to person with anything from a high temperature to a fast heartbeat to fever or chills. Sepsis is often mistaken for common infections like flu. Doctors are urged to start asking “could this be sepsis” earlier on so they rule it out or get people on treatment as soon as possible.

Professor Mark Baker, director of the NICE Centre for Guidelines, commented: “When hospitals are well prepared, clinicians do better at responding to patients with sepsis.”

The new NICE guidance details signs and symptoms clinicians should look out for and describes the tests that should be used to diagnose and monitor patients. Symptoms are broken down by severity and it describes where patients can be best treated.

High-risk patients should be transferred to hospital via ambulance and seen by a senior doctor or nurse immediately so that treatment can be started. Antibiotics should be given to patients who meet the high-risk criteria set out in the guidance.

Check out the new NICE guidance at www.nice.org.uk/guidance/ng51. The UK Sepsis Trust is also working with NICE to update their range of clinical toolkits in response to the guidance. Find out more at sepsistrust.org.

Jim Killgore is an associate editor of GPST