Sepsis is the body’s extreme response to an infection. When it is recognized early and treated promptly, most patients recover. When it is not, the consequences are catastrophic and they happen quickly. Septic shock has a mortality rate that has barely improved in decades, and the single most important determinant of survival is how fast the diagnosis is made.
A 2023 study published by the Society of Critical Care Medicine examined diagnostic delays in sepsis using Canadian medico-legal data from the Canadian Medical Protective Association. The findings are sobering. The mortality rate among the patients in the study was 49 percent. The specialties most often implicated were family medicine, emergency medicine, and surgery. Almost half of the patients had multiple visits to outpatient care before sepsis was finally recognized. Most cases involved a deficient assessment, including a failure to include sepsis in the differential diagnosis at all.
What sepsis is, and why early recognition matters
Sepsis is organ dysfunction caused by a dysregulated immune response to infection. The underlying infection can come from almost anywhere: pneumonia, a urinary tract infection, a wound infection, a post-surgical complication, an abdominal infection. What makes sepsis dangerous is not the underlying infection but the way the body responds. Blood pressure can fall. Organs can begin to fail. The patient’s condition can move from “feeling unwell” to “critically ill” within hours.
The corollary is that early recognition saves lives. Modern sepsis care is built around the principle that “time is tissue.” Every hour of delay in starting appropriate antibiotics has been associated with a measurable increase in mortality. The Surviving Sepsis Campaign guidelines, accepted internationally as the standard of care, set out specific recognition criteria, screening tools (such as qSOFA), and time-bound treatment targets including fluid resuscitation, blood cultures, and broad-spectrum antibiotics within one to three hours of recognition.
Where the diagnostic failures happen
The study identified consistent themes in cases where sepsis was missed or delayed. In my own experience these themes also recur in Ontario malpractice cases involving sepsis.
Sepsis is not on the differential. The most common pattern is that the clinician simply does not consider sepsis as a possibility. The patient is sent home from the emergency department or the family medicine clinic with an explanation that fits the most prominent symptom (a viral illness, gastroenteritis, a urinary tract infection treated with oral antibiotics, post-operative pain) and the systemic picture is not put together.
Multiple visits without recognition. The study found that almost half of patients had multiple outpatient visits before sepsis was diagnosed. Each repeat presentation should raise the index of suspicion. When a patient returns sicker than they were on the first visit, particularly with abnormal vital signs or a clinical picture that does not fit the original explanation, that is a signal that demands a rethink.
Vital signs not acted on. Heart rate, respiratory rate, blood pressure, and temperature trends are the early warning system. Single abnormal readings can sometimes be explained away. Trends in the wrong direction usually cannot. A documented fever, tachycardia, and hypotension in a patient with a known infection source is a sepsis screen until proven otherwise.
Reliance on telephone or virtual assessment. The study specifically flagged the importance of in-person assessment. Sepsis recognition depends on the things that cannot be heard over the phone: how the patient looks, the breathing rate, mental status, capillary refill, the warmth of the extremities. A reluctance to bring a patient back for an in-person review, or to admit them, is a recognized risk factor for delayed diagnosis.
ICU care was rarely the source of criticism. Almost forty percent of the patients in the study were admitted to ICU during their hospitalization, but care delivered in ICU was rarely the basis for the medico-legal concern. The diagnostic failures were upstream, in family medicine, emergency departments, and surgical services. By the time the patient arrived in critical care, the window in which the outcome could most readily have been changed had often already closed.
When delayed diagnosis becomes malpractice
A delayed sepsis diagnosis is not, by itself, evidence of negligence. Sepsis can present subtly. The textbook signs are not always present at the first visit. A reasonable physician may, in good faith, not recognize sepsis at the earliest possible moment.
The legal question is whether the care provided fell below the standard a reasonable practitioner would have provided in the circumstances, and whether that failure caused the harm. In sepsis cases, the standard-of-care analysis usually focuses on whether reasonable steps were taken to consider sepsis as a possibility, to gather the information needed to confirm or rule it out, and to act on the findings in a clinically appropriate timeframe. The causation analysis usually focuses on whether earlier recognition would, on a balance of probabilities, have changed the outcome.
What patients and families should do
If you suspect a delayed sepsis diagnosis contributed to the death or serious injury of a family member, the most useful first step is to obtain a complete copy of the medical records: the chart from each presentation, the vital signs, the laboratory results, and the documentation of the clinician’s reasoning at each visit. Those records, reviewed by a malpractice lawyer and the right medical experts, will usually answer the question.
For more on the legal process, see Suing for Medical Malpractice in Ontario: What You Need to Know. The relevant practice areas are Misdiagnosis, Emergency Room Delay, and Hospital Negligence.
The first conversation is free and strictly confidential. The earlier we look at the records, the better.
