This report summarises the findings of investigations into ten deaths from sepsis which have deemed to be avoidable. It highlights clinical and organisational issues in detail which contributed to the failure of care in each of the ten deaths. The report then goes on to discuss themes across all of these deaths and sets out recommendations and quality standards for safe sepsis care.

Key recommendations from the report include ways in which severe sepsis can be recognised earlier in primary care, the importance of listening to patient’s relatives, the need to involve senior staff early in the care pathway in secondary care and understanding why available guidance is not adhered to in clinic