How are you doing . Im all right, how are you. How are you dad . Good to see you. Its almost three years since my mother died. Every family get together is still bitter sweet. Weve had to come to terms with her not being around. She might still be with us had she received better care in hospital. Doctors missed the warning signs of a life threatening condition sepsis. Talking about the day my mother fell ill isnt easy. She woke up in the morning and said, ive neverfelt as ill as this before. That was when i sprang into action to dial the nhs emergency number. Did you think she was like potentially seriously ill at that point . No absolutely not. Because she walked herself down stairs and got into the ambulance. My brother was with her the next day. Her condition worsened. We sat in the room with her and from being able to speak, she suddenly stopped speaking, started to complain about feeling very hot and then having lots of pain in her lower body. Then she became slightly incoherent. Gasping for breath actually. She quite clearly said to me at one point, oh, god is this the end . I said, no, dont be silly, of course its not. I think those virtually were the last words she ever uttered. To you . Yes. God. At 78 my mother Margaret Jackson was just getting to know her new grandson, she was the heart of our family. My parents had been married for 50 years. When i reached the hospital, she was in icu. She passed away that night. It only took a weekend. I still think about it all the time. It is an unanswered question. Your mind says if there were a better reaction, would the outcome have been the same . I have no idea. I know for a fact she went in there not very ill and inside 48 hours she was dead. We were later led to believe that Heart Disease had caused her death, but we didnt feel wed been given the whole story. Im an investigative reporter, so i decided to look into my mothers death. I studied her medical notes in detail. In the week before shed died, shed seen her gp and had been treated for a urinary tract infection. In the elderly, this is a well known cause of sepsis. Sometimes called the silent killer, sepsis is triggered by an infection. If the bodys immune system overreacts, it can lead to multiple organ failure and death. The scale of this problem is enormous. Sepsis affects a quarter of a Million People across the United Kingdom every year. It causes more deaths than breast cancer, bowel cancer and Prostate Cancer put together. Ron daniels is a consultant in Critical Care and one of the worlds leading experts in sepsis. He agreed to meet me, having earlier studied my mothers medical notes to see if sepsis had been a factor in her death. I think what we have here is a classic loss of situational awareness. Your mother presented to hospital, complaining of, literally, symptoms of a urinary infection. She also had some chest pain. There was abnormal observations and we know in that situation, we should screen for sepsis. Do you see any evidence in the notes that sepsis was considered at that early stage . Theres no evidence from the notes that sepsis itself was considered even in the face of abnormal observations and even when she started to deteriorate very quickly. The symptoms of sepsis can look like other conditions in the early stages. So doctors need to be on the lookout. If suspected, it has to be treated quickly with antibiotics. A doctor later prescribed them for my mother, but there was a further long delay before they were given to her. She received them eventually. But its clear that she received them too late. There was opportunity to administer antibiotics several hours before they were ultimately administered. Obviously its quite hard to hear that. Can you tell me whether that would have made a difference ultimately or not . I think its unlikely that earlier antibiotics would have done any harm and its entirely possible that they might have improved her chances of survival. So its potentially a serious failure really. Potentially, yes. The hospital had told my family nothing about these failings after my mothers death. So i went back to the queens hospital in burton on trent armed with this evidence and only then did they admit that my mother hadnt received an acceptable level of care, for which they apologised. It had taken two years to get to the truth. With better treatment my mother might still be with us today. My family are not alone in our quest for answers. Sepsis is a leading cause of preventable deaths. At least 14,000 people die needlessly each year, not just in Emergency Departments, but across the Health Service. They could be saved if they were diagnosed and treated more quickly. In leeds, i went to meet angela meehan. Her husbands sepsis wasnt diagnosed quickly enough. Dean broke his hip and needed routine surgery after falling outside his local supermarket. He was 52 years old. Within days of the operation, he seemed to be recovering well. We thought, this is going to be a fairly quick thing. Hes already up and about on his feet with the aid of crutches and isnt medical technology fantastic. You know, this is so quick. When dean began to feel ill, he went back to the orthopaedic clinic where he was told there was no cause for concern. Alarmed at his deteriorating condition, angela returned to the clinic on two further occasions. Patients who have recently had surgery have a higher risk of infection, so they are more likely to develop sepsis. He said he felt ill. He had never felt he had neverfelt so ill. Every single visit to the hospital we explained that his health was deteriorating. I said explained that his health was deteriorating. Isaid he explained that his health was deteriorating. I said he is a wreck, he cannot set up straight. He was slumped, his head was down and he could not focus on anything. The pain was so all and competency in. Was there any mention of possible infection . No. Not at any point. Any tests carried out . No not at all. The original surgeon took action and recommended further surgery. He was sent for further tests. The co nsulta nt sent for further tests. The consultant was phoned as soon as results came back. Only then did sepsis become a concern. He sounded very worried, extremely concerned, could we get dean to hospital as soon as possible . They were really concerned about the high level of infection. High levels of infection pointed to life threatening levels of sepsis. He was taken to a knee but it was too late and he died four days later. It is so one real. You dont die like this in 2016. It is not right. I asked why they had missed this infection. I wanted to know why he had died. Leeds Teaching Hospitals nhs trust has told panorama its investigation into dean meehans case concluded it wasnt straightforward, and that there were no obvious early indications of sepsis. It said it has reiterated its condolences to his family. Dean meehans Case Highlights the need for clinicians across the Health Service to be more alert to the risks of sepsis. Since 2015, nhs england has been trying to find out how many patients with the signs of sepsis are being spotted by doctors in acute hospital trusts. Panorama has been given exclusive access to the numbers. In all, 104 hospital trusts took part. Ten said they were identifying every suspected case from the total sample. But though were some alarmingly poor performance. Across 1a hospital trusts, of every coup patients with signs of sepsis, only one was spotted. The queens hospital in burton is one of the trusts that has taken part. For me, its Performance Matters more than any other. Since my mother died, a new medical director has taken over, and he agreed to meet me. How many people were coming here that should have been screened for sepsis and werent . If i look at our data for the First Quarter of 16 17, only 1 of people were being appropriately screened. Nearly two years since my mother died, and you are still screening at that point, 1 of people . Yes. Why wasnt that problem tackled sooner . It was being tackled, it is whether it was effectively. It wasnt that we turned a blind eye to it at all. We were aware of it, and it was about having the right things in place to allow the screening to be there. Did the address it as quick as we could have done . Probably not. The hospital says it is making vast improvements and is now identifying 99 of emergency patients with the signs of sepsis. Sepsis is estimated to cost the nhs £1. 5 billion per year. Those that survive can be left with life changing injuries. They know only too well the financial and emotional cost that comes with surviving the condition. Tom ray was newly married when he fell ill 17 years ago. They removed my face. It died, basically. Everything below my eyes was dead, so it had to be cut away, and obviously, the effect on my Mental Health from having to live with a face thats reconstructed and different is quite, quite profound. With every minute that the sepsis went undiagnosed, i was deeper into that likelihood of ending up with all four amputations. I lost both of my arms and legs, and i know, from long experience, how even just saving one of those limbs would have transformed my life. Before he fell ill, the couple were running their own business. Tom now works part time in a call centre. Each day, tom deals with the consequences of not having received the urgent care he needed in those critical first few hours. Im sitting here, the product of 17 years of an nhs trying to catch up with what went wrong, and you know, if you put a figure on it, i must have cost the nhs well in excess of £1 million to keep on the road, just because of the failure of not devoting that urgent care in the first few hours. How difficult is it for you for me to come here and tell you that my family have suffered because sepsis wasnt properly spotted and screened in the hospital . It makes me very angry, and very disturbed. I dont think the nhs medical system is geared up for investigation and looking back and learning from the results. It doesnt actually have to be about beating people up for having made mistakes, because it is an easy thing to make mistakes with, but it is actually about fessing up and learning for what went wrong so that it doesnt go wrong the next time. I wanted to understand the challenge doctors face in quickly identifying patients who may be developing sepsis. Nottingham has one of the busiest hospital trusts in the country. Here, its leading the way in treating sepsis patients. The key to spotting this condition quickly is vigilance. Clinicians are constantly on the lookout for signs of infection, which can trigger sepsis. Just come to have a check of your Blood Pressure, if its alright . The observations of all patients are fed into a centralised system. The Computer System is looking out for signs of sepsis, and its looking out for people who may have infection and are deteriorating. You can see, his Blood Pressure is starting to drop down, and that is a concern. He will start to trigger for sepsis quite quickly. Clinicians are instantly alerted to any patients at risk. This information is static on here, but it is also very active on the mobile phone, so were sending messages out to people, saying, youre patient may have sepsis. Is it that speed that is absolutely critical, isnt it . Absolutely. It is all about information needs. Its all about getting information about a patient to the right people at the right time. When the condition is suspected, the patient is seen as quickly as possible by a senior clinician. To give the best chances of survival, treatment with antibiotics should start within an hour. All clinicians need to be aware that they should suspect sepsis and be aware of the criteria for assessing the severity. And any patient who may have higher risk sepsis, we should start antibiotics promptly in those patients, always. If those are not started in a timely manner, we know that patients deteriorate rapidly, and it can prove fatal. It is really time crucial. And here, they found that owning up to mistakes has driven improvement. The trust reviews the notes of every sepsis patient within a week of treatment. When we were auditing cases, we started to give individual feedback to doctors and nurses about how they had treated a patient. We effectively gave a traffic light report saying, yes, you did this right, but maybe next time you could improve things. We found that was actually an incredibly effective way of communicating and, in fact, educating people about sepsis care, and what we expect to happen when someone is recognised as having severe sepsis. What this trust has done shows that sepsis can be tackled effectively. In health care terms, it isnt hugely costly or revolutionary, but it has worked, sharply reducing the number of deaths from sepsis. Across england as a whole, the picture is less positive, though it is improving. The nhs data we have analysed reveals that, overall, only six out of ten patients that need antibiotics are getting them within the first hour. 2a of the trusts only gave them to half of the patients that needed them within the hour. The picture that emerges is of a postcode lottery. Care standards can vary according to where you live. As i discovered, my mother had eventually been prescribed antibiotics, but it was another three hours before she was given them. And two years on, burtons Emergency Department is still performing poorly. So according to your own figures, more than 50 of patients who you screened as needing treatment for sepsis are not getting it within an hour . Yes, thats correct. Thats still appalling, isnt it . Its, um, its not where we would want to be. The issue for me is, how do we improve on that . This is a medical emergency. It is time critical, its in a busy Emergency Department, theres lots of competing interests, but its still not ideal, and i completely accept your point. So when my mother came into this hospital three years ago and didnt get antibiotics for hours, more than 50 of people are still experiencing that situation here today. Yes. However, can i tell you what were doing to address that issue . We have trained ten of our emergency senior nurses one on every shift to actually recognised sepsis and give the Broad Spectrum antibiotic without the need for prescription. It is clear the nhs is trying to make improvements, but those changes have been slow in coming. Four years ago, the Health Service ombudsman was so concerned by the number of preventable deaths that it demanded the nhs urgently introduce treatment guidelines to spot sepsis. When there was still no action, those in charge were hauled before mps. Your innate caution might be slowing your response in a way that is actually costing lives. I understand the frustration about slowness, and i did give this absolute top priority. We moved it through our systems. Well, god help us, if it wasnt a priority, how long would it take then . I think that makes the point. Sepsis has been a problem in the nhs for a decade or more, identified as a problem, and yet, the slowness with which the system is dealing with the problem and addressing it is astonishing. Statistically, the longer it takes for the nhs to put into practice the procedures and techniques in order to make sure that sepsis doesnt infect patients, the more lives will be lost. One year old william mead is one of the lives that have been lost. Gps missed his sepsis. Like me, his mother, melissa, had to fight to discover the truth about what had happened. I stopped counting, 600 e mails in, i think, three months. They had this train of thought, it seemed to me that, ok, something has gone wrong here. What is the least amount we can do, or the least amount of information that we can give that will make these people go away . Now a prominent campaigner, melissa believes the nhs has to become more honest and open about its mistakes. For me, it was a bureaucratic nightmare, and i had to be a constructive nuisance in order for that door to be slightly opened. It shouldnt be like that. Was it difficult being a nuisance, with everything that was going on emotionally for you . Extremely difficult. At a time when. Ijust wanted the ground to swallow me up. I had to look at williams death objectively and almost put to one side my feelings, my emotions. It completely drained me and pushed our family into a black hole. An official report by the nhs into williams death admitted to a catalogue of failures. At williams memorial service, the Health Secretary, jeremy hunt, made a personal apology. Ive come here today to say sorry because, this weekend, william should have been enjoying beautiful cornish sunshine with his parents, and because we i as Health Secretary the government, the nhs, let down william, paul and melissa, we didnt spot his sepsis before it was too late. The Health Secretary pledged to make changes. Melissa persuaded him to bring in a nationwide Sepsis Campaign targeted at the parents of young children. Was it still difficult to get the nhs to sign up to an Awareness Campaign . I dont necessarily think it was difficult. Its almost as though you are in a position where you have to persuade someone, and i think the numbers speak for themselves. Thats the persuasion how many people have to die before people will do something about it . I wanted to ask the Health Secretary if he thought lives were still being lost because of poor care. We have let down too many people over too many years, but i think the story over the last two years is that weve introduced standards now and we think weve saved nearly 1000 lives as a result of the changes we brought in since 2015. But does that mean that we are still losing lives today because not everywhere is matching the standards of the best places . Im afraid it does, and so there is a lot more work to do. The full extent of the crisis isnt known. The part sepsis has played in deaths is often not recorded, especially in elderly patients. They are far more vulnerable to the infections that trigger sepsis, and being more alert to it would greatly improve their overall care. She was doing this that saturday morning. Lorraine caters mother, toni, had been enjoying an active and healthy retirement. We were not ready for mum to go, mum was not ready for mum to go. Mum had plans, she had a future ahead of her. Last october, she collapsed in the familys home with pains in her stomach. She was so unwell that lorraine called an ambulance. Several hours later, mum had deteriorated, so she was in cold sweats, she was constantly being sick, she was really crying out in pain. When you got to hospital, was there a sense of urgency . We were left waiting for mum to be seen for quite some time, and then she was examined by a doctor, who was just about to finish shift and who then left. No, there was no sense of urgency. Tonis deteriorating condition should have prompted a sepsis assessment by a senior clinician. A later investigation by the hospital confirmed that this would have identified that it was likely that sepsis was present. Instead, she was discharged. Hours later, she was rushed back to hospital. We just knew that we couldnt wait for an ambulance to come, so we took her there. Quite early on in the journey to hospital, i was holding mum in the back of the car. Ijust felt her go. She was resuscitated at the hospital and underwent surgery to remove infected bowel tissue but never recovered. The test that would have confirmed whether she had sepsis had not been carried out. As i understand it, vital signs that were taken when we were admitted to a e should have raised a warning flag. If they had just picked up, you know, her heart rate had increased, her temperature had dropped, her pain score was through the roof. Screening and looking for sepsis would have revealed the problem, you think . It would have revealed it, definitely. The chances of her surviving if they caught her as it was happening, it was there. Kettering hospital apologised to lorraines family for the gaps in care. They told us there is now clear guidance on the use of appropriate sepsis screening. Later this year, the nhs will insist on the standard of sepsis care it expects from all hospitals in england. It is also promising to be more accountable. Unfortunately, i am coming here today telling you that it took me, my family, two years to find out that sepsis was potentially an issue in the case, and weve spoken to other people who are experiencing the same thing. Well, that is totally unacceptable. I think you would find that a number of trusts now would never let that happen, because they have got their culture around safety and honesty right, but i wouldnt pretend that we get this right everywhere. We are on a journey. We definitely need to do a lot better, but i think we have made significant progress. It is almost three years since my mother died. Though during her life, she had received excellent care in the nhs, when it mattered most, she was badly let down. When andrew and i started looking at what had gone on, did you ever expect we might find Something Like this . No, ididnt. I knew it wouldnt have been her wish to stir up trouble and difficulties for anybody. And then, as this situation unfolded, i became grateful to you for doing it, because i could see the public necessity to focus on this and prevent other people from suffering as we undoubtedly did. We now know why mum died, but too many lives are still being lost to sepsis. Change cant come quickly enough. Know if you welcome to bbc news, broadcasting to viewers in north america and around the globe. My name is tom donkin. 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