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Preventable deaths involving sepsis in England and Wales, 2013–2022: a systematic case series of coroners’ reports

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Abstract

Purpose

Coroners’ Prevention of Future Death (PFDs) reports are an under-utilized resource to learn about preventable deaths in England and Wales. We aimed to identify sepsis-related PFDs and explore the causes and concerns in this subset of preventable sepsis deaths.

Methods

Four thousand three hundred five reports were acquired from the Courts and Tribunals Judiciary website between July 2013 and November 2022, which were screened for sepsis. Demographic information, coroners concerns and responses to these reports were extracted and analyzed, including a detailed paediatric subgroup analysis.

Results

Two hundred sixty-five reports (6% of total PFDs) involved sepsis-related deaths. The most common cause of death in these reports was “sepsis without septic shock” (42%) and the most common site of infection was the respiratory system (18%) followed by gastrointestinal (16%) and skin (13%) infections. Specific pathogens were named in few reports (27%). Many deaths involved multimorbid patients (49%) or those with recent surgery (26%). Coroners named 773 individual concerns, the most frequent were: a failure to keep accurate records or notes (28%), failure in communication or handover (27%) or failure to recognize risk factors or comorbidities (20%). Paediatric cases frequently reported issues with sepsis screening tools (26%). Sepsis PFDs resulted in 421 individual reports being sent, of which 45% received no response. Most organisations who did respond acknowledged concerns and initiated a new change (74%).

Conclusion

Sepsis-related PFDs provide valuable insights into preventable causes of sepsis and identify important sources of improvement in sepsis care. Wider dissemination of findings is vital to learn from these reports.

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Data availability

All study materials are available on the Open Science Framework repository for this project (https://osf.io/rg63x/).

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Funding

No funding was obtained for this study. The National Institute for Health Research (NIHR) School for Primary Care Research (SCPR) provided seedcorn funding to establish the initial development of the Preventable Deaths Tracker website (2021–2022): https://preventabledeathstracker.net/.

Author information

Author notes

  1. Jessy Jindal and David Launer have contributed equally to the generation of the manuscript.

Authors and Affiliations

  1. Medical Sciences Division, University of Oxford, Oxford, OX3 9DU, UK

    Jessy Jindal, David Launer, Harrison S. France, Molly Hey, Kaiyang Song, Clara Portwood & Francesco Dernie

  2. Centre for Evidence-Based Medicine, Nuffield Department of Primary Care Health Sciences, University of Oxford, Radcliffe Observatory Quarter, Woodstock Road, Oxford, OX2 6GG, UK

    Georgia Richards

  3. Oxford University Hospitals NHS Foundation Trust, Oxford, OX3 9DU, UK

    Francesco Dernie

Authors
  1. Jessy Jindal
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  4. Molly Hey
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  6. Clara Portwood
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  7. Georgia Richards
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  8. Francesco Dernie
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Contributions

FD conceptualised the project and wrote the code used to download and screen the PFDs. GCR created the Preventable Death Tracker and established the methodology to analyse PFDs. FD wrote the study protocol. All authors were involved in screening the PFDs for inclusion. DL and JJ performed the data extraction and data synthesis and wrote the manuscript. All authors were involved in interpretation of the results. All authors have read and endorse the findings of the final manuscript.

Corresponding author

Correspondence to Francesco Dernie.

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Conflict of interest

KS, CP, JJ, DL, MH, and FD report no interests. GCR is the Director of a limited company that is independently contracted to work as an Epidemiologist and teach at the University of Oxford. GCR received scholarships (2017–2020) from the NHS National Institute of Health Research (NIHR) School for Primary Care Research (SPCR), the Naji Foundation, and the Rotary Foundation to study for a DPhil at the University of Oxford. HSF has received scholarships (2020–2022) from Brasenose College, University of Oxford, and Fidelity National Information Services for undergraduate study. No funding was obtained directly for this study. GCR received a Seedcorn and Engagement and Dissemination grant from the National Institute for Health Research (NIHR) to establish the Preventable Deaths Tracker (2021–2022). The NIHR was not involved in the design, conduct, interpretation, writing or decision to submit this paper for publication.

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Jindal, J., Launer, D., France, H.S. et al. Preventable deaths involving sepsis in England and Wales, 2013–2022: a systematic case series of coroners’ reports. Infection (2023). https://doi.org/10.1007/s15010-023-02140-6

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