What will it take for sepsis awareness to take effect?
Each time I settle a fatal sepsis case for a family whose relative has died because the infection was not treated quickly enough by hospital doctors, my heart sinks that yet again the message around sepsis identification and management has not got through.
A terrible case was reported by the BBC this week after a coroner issued yet another Prevention of Futures Deaths warning following the death of a 10-week-old baby at Kings Mill Hospital, Nottinghamshire.
The coroner heard that the seriousness of the baby's infection was not recognised for nearly five hours. He was admitted at around 12 o'clock but assessment was delayed, the severity of his condition was not picked up and correct treatment with antibiotics and fluids did not start until 5pm. He died the next day.
Sherwood Forest Hospitals NHS Foundation Trust which runs the hospital said it was working on a 'rapid' programme of improvements, not least since the Corner highlighted problems with the systems in A&E for assessing an ill baby and identified a lack of experienced paediatric nurses and confusion in handovers between staff.
Coroners issuing PfDs around sepsis deaths must also despair that they seem to be highlighting the same problems over and over again: an inability of staff to recognise sepsis quickly and treat it. In most cases, where efficient and timely treatment is given, it saves a person's life.
A case of mine involving missed diagnosis of sepsis was also reported more than a year ago by the BBC, about the same time I caught sight of several ambulances carrying the sepsis aware messaging, part of initiative run by the UK Sepsis Trust in partnership with the London Ambulance Service.
The coroner in my case also issued a PfD and concluded that Mr Blewitt's death was avoidable. You can imagine the despair of Mr Blewitt's family hearing such a terrible blow.
When I settled an all too similar case a few months later, I spoke to a trusted journalist at the Observer to discuss another piece to raise awareness around sepsis. His reluctant reply was that the paper could not keep on reporting the same issues time and again. To put it bluntly, he said, it is no longer news.
It would be a terrible state of affairs if overworked hospital staff have also become deaf to the urgency of better understanding of sepsis. Rather shockingly, in a recent inquest relating to another death at the same hospital Trust that treated Mr Blewitt, we heard evidence from Trust staff that there is no mandatory nor specific training on sepsis identification and management for either new or existing staff at the hospital. Perhaps if there was mandatory training, deaths would be avoided.
All we can do is to keep reporting the stories and highlighting the issues in the hope that the message gets through and there is better training for staff within NHS Hospitals.