In our recent webinar, Consultant in General and Acute Medicine Dr Elora Mukherjee explored these issues through clinical examples and medico-legal analysis.

Watch the full webinar with Dr Elora Mukherjee here >

Recognising Sepsis and Deterioration

One of the central difficulties in sepsis is that early symptoms may be non-specific.

A patient may initially present with fever, increased heart or respiratory rate, confusion, reduced urine output, hypotension or an increasing oxygen requirement. However, Dr Mukherjee stressed that these features do not appear uniformly in every patient.

The patient's physiological reserve matters.

Older people, children and immunocompromised patients may not mount the same inflammatory response as a younger, otherwise healthy adult. Fever may be absent. White cell count or CRP may not be significantly elevated. Blood cultures may also be negative, particularly where antibiotics have already been started before hospital admission.

That makes the trend in a patient's condition particularly important.

A single NEWS score may provide useful information, but Dr Mukherjee emphasised the need to review how observations develop after treatment. Is the patient stabilising? Are they deteriorating? Has the lactate improved? Is the blood pressure continuing to fall?

For solicitors reviewing the records, the issue may therefore be less about an isolated number and more about whether the clinical team recognised the developing pattern.

“One [NEWS score] isn't enough. With treatment, you need to reassess and see which way it's going.”

Reassessment and the First 24-72 Hours

Reassessment is a recurring theme in potential sepsis claims.

A clinician may reasonably begin with a working diagnosis such as a viral illness or urinary tract infection. But that diagnosis should not become fixed if the patient's subsequent clinical course no longer supports it.

Dr Mukherjee highlighted the importance of reviewing patients who fail to improve and reconsidering the original diagnosis after treatment has been started.

This becomes particularly significant during the first 48-72 hours.

By this stage, questions may include whether:

• empirical antibiotic treatment is working;
• microbiology advice is required;
• culture results provide evidence of a particular organism;
• further imaging or investigation is needed;
• organ dysfunction is worsening;
• specialist input should be requested; and
• HDU or intensive care review is becoming necessary.

In a medico-legal review, a treatment decision that appeared reasonable at the outset may therefore need to be considered alongside what happened afterwards.

Treatment, Escalation and the Sepsis Six

Dr Mukherjee also discussed the Sepsis Six as an important framework when sepsis is suspected.

This includes oxygen where required, blood cultures, antimicrobial treatment, intravenous fluids, measurement of lactate and monitoring urine output.

The webinar highlighted that treatment itself also requires review.

For example, fluid may be necessary to support a patient with hypotension, but the volume administered needs to be monitored alongside urine output and the patient's underlying condition. Equally, antimicrobial treatment may initially be empirical, before being refined as further microbiology information becomes available.

For solicitors, the relevant question may not simply be whether treatment was given. It may be whether it was given at the appropriate time, whether its effect was reassessed and whether management changed when the patient remained unwell.

Escalation can be equally important.

Dr Mukherjee described the typical hospital pathway from the Emergency Department into acute medicine and, where necessary, enhanced or high dependency care and intensive care.

The timing matters.

A patient showing worsening organ dysfunction may require critical care input before they reach the point of extreme deterioration.

Records may therefore need to be reviewed for evidence of:

• repeated NEWS observations;
• Critical Care Outreach involvement;
• intensive care review;
• treatment escalation planning;
• specialist referrals; and
• communication with the patient or family about the expected clinical course.

Medico-Legal Considerations: Breach and Causation

One of the clearest messages from the webinar was that breach and causation must be considered separately.

There may have been a delay in diagnosis, an imperfect treatment decision or a missed opportunity to reassess. But that does not necessarily mean that the delay caused additional injury.

The causation analysis requires another question:

What would probably have happened if appropriate action had been taken earlier?

For example, if a diagnosis was delayed but the patient subsequently received the correct treatment and recovered without additional injury, a potential breach may not translate into recoverable damage.

By contrast, where the evidence suggests that deterioration occurred during a period in which reasonable intervention could have taken place, the causation question may become much more significant.

Dr Mukherjee suggested focusing on three core issues:

Was there an unreasonable delay in diagnosis or treatment?

Did the patient's condition deteriorate during that period?

Would earlier intervention probably have changed the outcome?

That distinction is particularly important in sepsis claims because the condition can progress rapidly even where clinicians are treating the patient appropriately.

“There can be breaches… but breach and causation is separate.”

Case Example One: Recognising Severe Sepsis Early

The first case concerned a 56-year-old woman who had already received antibiotics from her GP for suspected urinary infection.

Three days into treatment, she remained unwell and presented with vomiting, confusion and shaking.

Her observations included profound hypotension, tachycardia, fever, reduced oxygen saturation and an elevated respiratory rate. Her NEWS score was 14.

Blood results also showed evidence of significant illness, including renal impairment, raised inflammatory markers and an elevated lactate.

For Dr Mukherjee, this was a patient who was critically unwell from presentation.

Potential medico-legal issues included whether the severity of her condition was recognised, whether observations were appropriately trended, whether treatment produced an adequate response and whether intensive care involvement occurred sufficiently early.

The example also demonstrated why simply establishing that something could have been done differently is not enough. If treatment ultimately corrected the problem without additional harm, causation still has to be established separately.

Case Example Two: When the Diagnosis Is Not Sepsis

The second case demonstrated the importance of taking a complete clinical history.

A 56-year-old Ghanaian man presented with fever, rigors, headache, body aches and red urine. A urinary infection was initially suspected.

However, several findings did not fit neatly with that diagnosis.

His platelet count was reduced, his clotting was abnormal and the history of a recent wedding became highly significant when Dr Mukherjee asked where the wedding had taken place.

It had been in Ghana.

The eventual diagnosis was malaria.

The example illustrates a broader point for clinical negligence investigations: a patient may look physiologically septic without a conventional bacterial infection being the underlying diagnosis.

Travel history, sexual history and other contextual information can materially alter the differential diagnosis.

For solicitors, the records may therefore need to be reviewed not simply for what clinicians recorded, but for whether relevant information was sought in the first place.

Case Example Three: Failure to Reconsider the Original Diagnosis

The third case focused on a 64-year-old woman attending Same Day Emergency Care with fever, rigors, nausea and right-sided abdominal pain.

She was initially treated for pyelonephritis and received intravenous antibiotics.

Her observations improved sufficiently for ongoing SDEC management, but her symptoms persisted.

The eventual issue was that the original diagnosis had been wrong. The source was biliary sepsis.

For Dr Mukherjee, the significant point was what should happen when a patient fails to respond as expected.

At around 48 hours, the original diagnosis should be challenged rather than simply carried forward.

This is particularly relevant in environments such as SDEC, where different clinicians may review the same patient on different days and continuity relies heavily on accurate handover and documentation.

“The most important thing then is to review whether or not that initial diagnosis was the right diagnosis.”

Potential issues for solicitors include whether the patient was appropriately reassessed, whether persistent symptoms triggered further investigation, whether handovers were sufficient and whether there was an earlier opportunity to identify the true source of infection.

Investigations and Missed Sources of Infection

The webinar also highlighted the importance of investigating beyond the most obvious sources.

Chest X-rays, abdominal imaging, urine testing and blood cultures may form part of the initial work-up. But where a patient continues to deteriorate without a clear explanation, further investigation may be required.

Depending on the clinical presentation, Dr Mukherjee discussed examples including:

• lumbar puncture where a central nervous system infection is suspected;
• skin and pressure-area examination;
• MRI where discitis or osteomyelitis is suspected;
• PET imaging in selected inflammatory presentations; and
• echocardiography or transoesophageal echocardiography where infective endocarditis is a concern.

The medico-legal question is not whether every investigation should have been performed in every patient. It is whether the evolving presentation gave reasonable grounds for further investigation and whether those opportunities were acted upon.

Differential Diagnosis Matters

Another important message from the webinar was that not every patient who appears septic has sepsis as the underlying diagnosis.

Dr Mukherjee discussed several differential diagnoses that can produce overlapping features, including autoimmune or inflammatory disease, malignancy, pancreatitis and bowel ischaemia.

This is particularly relevant where the patient does not respond to the treatment expected to improve their presumed infection.

A solicitor reviewing such a case may therefore need to ask:

Was the original diagnosis reasonable at the time?

Did subsequent information continue to support it?

Were reasonable alternative diagnoses considered when treatment failed?

Key Takeaways for Solicitors

Sepsis claims often need to be examined as a timeline, rather than around one isolated clinical event.

The records should help establish when the patient first showed evidence of deterioration, what clinicians knew at each stage and whether management adapted as the clinical picture changed.

Particular attention may need to be given to trends in observations, lactate results, NEWS scores, antibiotic timing, fluid management, reassessment, microbiology input, imaging, critical care referrals and the quality of clinical handovers.

Most importantly, potential breaches should then be considered separately from causation.

A missed opportunity only becomes causally significant if earlier reasonable intervention would, on the balance of probabilities, have produced a different outcome.

Watch the Full Webinar

Hear Dr Elora Mukherjee discuss early sepsis recognition, deterioration, escalation and the three clinical case examples in full.

Watch the full webinar here >