by Dr Terry McLoughlin, Expert Witness, McCollum Consultants & Emergency Medicine Consultant & Sepsis Lead
Dr Terry McLoughlin, Expert Witness, McCollum Consultants & Emergency Medicine Consultant & Sepsis Lead
The recent investigation by the Health Services Safety Investigations Body (HSSIB) into delays in recognising and treating sepsis is a sobering reminder that, despite years of national focus, sepsis continues to claim lives unnecessarily. As an Emergency Medicine Consultant of over seven years and Sepsis Lead for my Hospital, I see the reality of this every day.
The updated national sepsis guidance has rightly shifted towards more nuanced, risk-stratified approaches, moving away from a blanket ‘one-size-fits-all’ model, and recognising that sepsis exists on a spectrum. Yet while this approach is more clinically sound, it places even greater emphasis on clinical judgment and structured early warning tools, particularly the NEWS2 scoring system, which remains our most vital bedside tool for identifying deteriorating patients.
Recognising sepsis early is an increasingly complex challenge. Frontline clinicians are working in environments where decision-making must be rapid, yet the clinical picture is often blurred, especially when sepsis presents subtly or is masked by multiple comorbidities. Amid constant interruptions, rapid turnover, and competing clinical priorities, sepsis doesn’t always declare itself clearly, and the quiet cases are often the most dangerous.
Alongside a group of experienced and dedicated colleagues across departments, we have embedded robust systems of monthly data analysis tied to NEWS2 scores and sepsis criteria. I lead a regular review of performance data: looking at delays in recognition, time to antibiotics, outcomes, and compliance with escalation protocols. This process isn’t about blame, it’s about learning and improving. We examine both missed opportunities and examples of excellence to refine our approach and support teams with focused feedback and training.
What we’re seeing reinforces the importance of early escalation based on NEWS, especially in patients with a score of 5 or more. While no tool can replace clinical judgment, NEWS2 remains an essential and reliable aid in identifying patients at risk of deterioration. When applied consistently and thoughtfully, it plays a critical role in saving lives. However, the tool is only as good as the culture in which it’s used. We must continue to create environments where staff feel empowered to escalate concerns, even amidst the relentless demands of NHS shift work and corridor care.
From a medicolegal perspective, these failures also carry significant implications. In my role as an expert witness in sepsis-related cases, I regularly review instances where delays in recognition or treatment have led to avoidable harm. The courts are increasingly attuned to the role of early warning scores, system processes, and trust protocols. Where these are not followed or documented adequately, accountability is clear. For clinicians, that means the stakes are high. Clinical judgment must be robust, but so must the adherence to pathways, documentation, and timely escalation.
For experts preparing medicolegal reports, these issues underline the importance of scrutinising both individual clinical decisions and systemic factors. Reports should clearly set out whether early warning scores were recorded, interpreted, and acted upon in line with national and local protocols, and whether any deviations were reasonable in the clinical context. Experts must avoid hindsight bias by assessing the situation based on information reasonably available to the clinician at the time. For instructing parties, precision in the instructions given to experts is essential: framing questions that distinguish between failures of individual judgment and organisational or cultural deficiencies will ensure opinions address the root causes of harm, and not simply assign blame retrospectively. Both experts and instructing parties should remain mindful that robust, evidence-based analysis of adherence to early recognition pathways, or lack thereof will increasingly form the crux of legal arguments in sepsis-related cases.
The issues highlighted by HSSIB have been raised before, yet they remain as urgent and impactful as ever. This is not simply a clinical issue; it is a systemic one that demands collective accountability and meaningful change. To meet the standard of care our patients deserve, we must invest in adequate staffing, and ongoing education. We must foster a culture where clinical data is acted upon promptly and used to drive both immediate decisions and continuous improvement, starting at the front door of the hospital, where patients with sepsis first present, and where early recognition and escalation can make the greatest difference.
With the right tools, clinical vigilance, and system-wide commitment, we can change the story of sepsis and save more lives.
To instruct Dr Terence McLoughlin, please contact:
t: +44 (0)161 218 0223
e: info@exp-w.com