Sepsis is a potentially life-threatening complication of infection. Early recognition and timely treatment are critical, as sepsis can progress rapidly to organ failure and death.¹

Sepsis-related incidents continue to be reported on NIMS, the National Incident Management System, including cases where the diagnosis or management of sepsis was delayed.

The State Claims Agency is sharing this anonymised case study to share learning from claims analysis and support greater awareness of sepsis and improve its management.

Clinical Vignette

Clinical Vignette Summary

The patient, a young adult, presented to the emergency department (ED) of an acute hospital on three separate occasions over a five-day period with progressively worsening symptoms. The patient was discharged on each occasion.

Key Learning Points

• Sepsis can affect anyone at any age. ²
• It can be difficult to recognise early. Initial signs may be subtle, and deterioration can occur rapidly. ³
• Early sepsis may present with normal or only mildly abnormal vital signs, particularly in younger or physiologically resilient patients and often looks like many other, far more common conditions.
• Children and adolescents may have normal early vital signs despite significant underlying infection. Compensatory mechanisms can mask early shock.⁴
• Diagnosis relies heavily on clinical judgement and recognition of evolving patterns.⁵
• Clinicians must maintain a high index of suspicion, even when early vitals appear stable.⁶
• Early detection is essential because sepsis is a time-dependent medical emergency that can progress rapidly to organ failure and death if untreated.
• All health and social care staff should be familiar with, and guided by, the recommendations in National Clinical Guideline No. 26, Sepsis Management for Adults (including maternity).

References available on request