The case for a public inquiry into sepsis: Why it matters now

Sepsis remains one of the leading causes of preventable death in the UK, yet it continues to be under-recognised, inconsistently treated, and too often diagnosed too late. At RWK Goodman, our Inquest and Medical Negligence specialists have supported families who have lost loved ones, and whose lives have been irreversibly changed. These are not isolated incidents, but part of a wider systemic issue that demands urgent scrutiny.

There is a growing and compelling campaign calling for a full public inquiry into sepsis care in the UK. RWK Goodman support this call. Sepsis is a time-critical condition. When identified early and treated promptly, outcomes can be significantly improved. However, repeated failings in recognition, escalation, and treatment demonstrate that current systems are not working as they should. From primary care to emergency departments and postnatal settings, the same themes emerge: missed warning signs, delays in antibiotics, and failures in communication.

Organisations such as UK Sepsis Trust have long advocated for improved awareness, training, and systemic change. While progress has been made in recent years, including the introduction of sepsis screening tools and national guidance, these measures have not gone far enough to prevent avoidable harm. A public inquiry would serve several essential purposes. First, it would provide a comprehensive examination of the systemic failures that continue to lead to avoidable deaths and injuries. Individual cases, while tragic, often reveal recurring patterns that can only be properly addressed through a wider, coordinated review. Second, it would give a voice to patients and families. Too often, those affected by sepsis are left feeling unheard and without answers. An inquiry would offer an opportunity for transparency, accountability, and, importantly, learning. Third, it would drive meaningful and lasting change. Recommendations arising from a public inquiry carry weight and can lead to enforceable improvements in clinical practice, training, and resource allocation.

The need for such an inquiry is particularly stark in the context of maternity and neonatal care, where sepsis can progress rapidly and the consequences can be catastrophic. Cases involving delayed diagnosis of maternal or neonatal sepsis highlight the importance of vigilance, clear protocols, and effective communication between healthcare professionals.

Our Clinical Negligence Team represent M who appeared to be a healthy newborn baby. Following her birth, she was discharged home in good condition, with no immediate concerns raised. However, within days, subtle but significant warning signs began to emerge – signs that would later prove critical.

Our client was brought back to hospital with a three-day history of being generally unwell. Her parents noticed that she was unusually sleepy, not interested in feeding, and appeared jaundiced. Clinically, she had a raised respiratory rate and had lost approximately 220 grams since birth – equating to a 6.4% weight loss. Although her temperature was recorded as 36.5°C, which is not overtly abnormal, other observations painted a more concerning picture. She was tachypnoeic, with respiratory rates recorded between 56 and 60 breaths per minute. There were also reports of possible grunting when awake – an important clinical indicator of respiratory distress in newborns.

Blood gas analysis revealed results at the margins of normal: a low pH, increased base deficit, reduced bicarbonate, and a slightly elevated lactate level. These findings can be early indicators of metabolic compromise. Despite this, our client’s bilirubin level was measured at 190, significantly below the treatment threshold of 300, and the clinical focus appears to have remained on jaundice and feeding concerns.

Following assessment, our client was discharged home later that day with advice to return if her feeding did not improve. This decision would prove pivotal. At the time of discharge, our client exhibited a combination of symptoms that, when considered together – poor feeding, lethargy, tachypnoea, weight loss, and abnormal blood gas findings – were suggestive of possible neonatal infection. These are well-recognised red flags for sepsis in newborns and typically warrant close monitoring, if not admission for observation and further investigation.

Later that same evening, our client’s condition deteriorated dramatically. She was rushed back to hospital at approximately 11:00 pm in septic shock. On readmission, her heart rate was critically elevated, ranging between 190 and 200 beats per minute. She was grunting and displaying clear signs of respiratory distress, including intercostal and subcostal recession. Further examination indicated severe metabolic acidosis secondary to sepsis – a life-threatening condition requiring urgent intervention.

Despite treatment, including administration of the antiviral drug acyclovir, M’s condition did not improve.

Medical investigations confirmed a devastating combination of diagnoses:

• sepsis;
• meningitis;
• gram-positive bacterial infection in the bloodstream;
• seizure activity.

An MRI scan subsequently revealed a likely ischaemic brain injury.

Our client required anticonvulsant treatment, including phenobarbitone, to manage her seizures. Although she survived, the consequences of the delayed diagnosis were profound.
She was left with significant, permanent neurological damage.

Our client now lives with complex needs arising from her brain injury, including cerebral palsy and epilepsy. Expert evidence indicates that she faces an ongoing risk of seizures, including the possibility of sudden unexpected death in epilepsy. Her condition requires lifelong care, specialist support, and medical intervention.

From a legal perspective, we continue to see cases where the standard of care has fallen below what is reasonably expected, resulting in avoidable harm. While litigation can provide some measure of redress for affected families, it is not a substitute for systemic reform. A public inquiry offers the opportunity to move beyond individual accountability and address the root causes of these failures.

Ultimately, the campaign for a sepsis inquiry is about prevention. It is about ensuring that lessons are learned, that patterns are recognised, and that no more lives are lost to a condition that is, in many cases, treatable if identified in time.

We stand in support of those calling for change. A public inquiry into sepsis is not only justified – it is necessary.