When Sepsis Pathways Are Not Enough: The Danger Of Tick-box Medicine

In Part 2, I considered the aims of the new Modern Service Framework for sepsis. In this third part, I look at why sepsis still leads to clinical negligence claims, and why an overreliance on checklists and screening tools can create risks of its own.

Why does sepsis still lead to clinical negligence claims?

Despite national guidance, local sepsis pathways and the widespread use of sepsis screening tools, sepsis continues to give rise to clinical negligence claims. Some of the recurring themes seen within both my own practice and across my colleagues’ practice are all too familiar: failure to recognise sepsis red flags, failure to take or repeat observations, failure to calculate or respond to a NEWS2 score, or where a NEWS2 score is completed basing it upon incomplete data, delays in prescribing and administering antibiotics, inadequate senior review, poor escalation of care, failure to act on abnormal blood results, or failing to recognise a concerning trend in the blood results, premature discharge, and inadequate safety-netting. This list goes on.

In a sepsis clinical negligence claim, as with any other, the central question is whether the treating clinician(s) acted in accordance with a responsible body of medical opinion skilled in that particular art, and whether that failure caused avoidable harm. A medical negligence solicitor will often need to look closely at timings: when observations were taken, when a doctor reviewed the patient, when blood tests were requested and reviewed, when antibiotics were prescribed and administered, and whether there was any delay in escalating that patient’s care. These details are often critical and are made even more challenging when the records we receive are often incomplete, overly brief, or confusing to follow and decipher.

The dangers of “tick box” medicine

The MSF for sepsis rightly recognises the need for clearer systems and more consistent sepsis care. However, a potential drawback of any national framework is that it may promote Trusts to adopt a too rigid, formulaic approach to patient care, particularly where initiatives are introduced without adequate consideration being given to their practical implementation. Sepsis screening, a clearly defined sepsis pathway and tools such as a NEWS2 score are all important, but they are not a substitute for clinical judgement. A checklist may be completed and indicate that no further action is needed, yet it may fail to capture the fact that a patient’s condition is continuing to deteriorate. A box may be ticked, but the overall clinical picture may still be deeply concerning. If a patient does not fit perfectly into the parameters, that does not make their condition any less concerning.

This is particularly important where symptoms are atypical, evolving or difficult to interpret. A young child, an older person, a pregnant woman, a patient with communication difficulties, or a patient already unwell with another condition may not fit neatly into a standardised pathway. In those circumstances, “tick box” medicine can be dangerous if it discourages clinicians from taking a full history, looking at the patient in front of them and then taking a step back, reassessing that patient and asking whether the presentation as a whole makes sense. Good sepsis care not only requires protocols, frameworks, risk stratification tools and assessment parameters, but it also requires curiosity, a review of the entire clinical picture, caution and timely senior input.

In the final part of this series, I will consider where the Modern Service Framework has the greatest potential to improve patient safety, including the importance of better records, better learning from previous harm, and listening more carefully to patients and families.