Both of these are taught around a rash, and the rash is the least reliable part of either. That is not a small teaching flaw; it is the reason people wait.
Sepsis — the recognition problem
Sepsis is the body's response to infection damaging its own organs. It is common, it kills quickly, and it is difficult to recognise precisely because the early picture looks like the infection everyone already knows they have.
| Adults — ask for an urgent assessment or call 999 if |
|---|
| Slurred speech or confusion — new confusion in an unwell person is a red flag in its own right |
| Extreme shivering or muscle pain |
| Passing no urine all day |
| Severe breathlessness |
| It feels like you are going to die — this is a documented and startlingly specific symptom, and it should be taken literally |
| Skin mottled, ashen, blue or very pale |
| Children — the additional ones that matter |
|---|
| Breathing very fast, grunting, or long pauses in breathing |
| A weak, high-pitched or continuous cry, or not responding as they normally would |
| Floppy, very sleepy, or difficult to wake |
| Not fed or passed urine in the last 8–12 hours; no wet nappies |
| Cold hands and feet with a hot body, or mottled skin |
| A temperature below 36 °C, which is as concerning as a high one |
Trust a parent or carer who says this illness is different. Parental concern that a child is more unwell than usual is one of the better predictors in the entire literature, and it outperforms several measured signs. It belongs in the handover.
Why it gets missed — and what you can do about it
Sepsis is missed in emergency departments and general practice often enough that it is a recognised patient safety problem rather than an occasional lapse. The reasons are structural rather than careless, and knowing them is what lets a patient or a relative interrupt the pattern.
| How it happens | Why the mechanism works |
|---|---|
| The infection gets a name, and the name closes the question | “Chest infection”, “urine infection”, “a virus going round”. The label is not wrong — sepsis is an infection — it is incomplete. Once written down, subsequent findings get fitted to it rather than tested against it. This is the single commonest route to a missed diagnosis |
| One normal set of observations at the front door | Sepsis is a trajectory, not a snapshot. A patient whose pulse and pressure were fine at triage two hours ago may be a different patient now, and nobody has looked again |
| Young fit people compensate, then crash | A healthy 25-year-old holds a normal blood pressure until they are close to collapse. Normal numbers in a young adult who looks unwell are a warning rather than a reassurance |
| Older people and babies often have no fever | And may be cold. A temperature below 36 °C carries the same weight as a high one, and infants with sepsis frequently present hypothermic |
| Paracetamol has already flattened the picture | Given at home an hour before, it lowers the temperature and the pulse, and the person is assessed looking better than they are |
| “They were seen this morning” | A review four hours ago is not a review now, and in a condition that moves this fast a previous normal assessment is the least useful piece of information available |
| Waiting for the rash | Covered above, and it is worth repeating: the rash is late, unreliable, and sometimes absent |
| Immunosuppression removes the signs | Chemotherapy, steroids, biologics and immunosuppressants can abolish the fever and the inflammatory response while the infection progresses. These patients look better than they are, by mechanism |
The six things to say, and why each one works
Use the word. “Could this be sepsis? I would like it considered, and I would like that written down.”
This is the most useful sentence in this chapter and it is not rude. It converts an open question — what is wrong with this person — into a closed question about a named condition, and a closed question has to be answered. Asking for it to be documented is not an act of hostility; it is what makes the answer part of the record rather than part of a conversation. Sepsis pathways in UK hospitals are triggered by someone thinking of it, which is why saying it aloud is a genuine intervention rather than a gesture.
Give the trajectory, not the symptoms
“Yesterday he was at work. This morning he could not stand. In the last hour he has not known where he is.” That is a different sentence from “he has a cough and a temperature”, and it is the information that makes sepsis visible. It is also the only information you have and the clinician does not.
Say what is different from every other illness they have had
Carer and parental concern that this illness is not like the others outperforms several measured signs in the literature, and it is taken seriously by anyone who knows the evidence. Say it explicitly rather than hoping it is inferred.
Volunteer the things that change the risk before being asked
Recent surgery or any procedure; a catheter, line or other indwelling device; chemotherapy, steroids or immunosuppressants; no spleen, or sickle cell disease; pregnancy or the six weeks after it; injecting drug use; diabetes; a recent hospital stay; a wound. Each of these changes the probability substantially and several are routinely not asked about. Also say what painkillers were given and when.
Ask for the observations to be repeated before anyone is sent home
And it is entirely reasonable to ask what the score was — UK hospitals use a track-and-trigger score, usually NEWS2, and asking what it is and whether it has changed is asking about the trend rather than the snapshot. If bloods are being taken, a lactate and blood cultures are the two that matter here.
Ask the safety-net question, and get the answer in writing
“What specifically should bring me back, and how quickly?” A good answer is concrete. A vague one is itself information. And if you come back, say that you are coming back — “I was seen at two o'clock and she is worse” is a different presentation from a first attendance and should be treated as one.
If you are not satisfied
- Say you would like a senior review. Plainly and without apology. In a hospital that means a registrar or consultant; in general practice it means being seen again rather than advised by phone.
- Say what you are worried about rather than that you are worried. "I think she is getting worse and I am worried this is sepsis" gives someone something to act on. "I'm not happy" does not.
- Ask what would have to change for the diagnosis to be reconsidered. It is a fair question and it forces the reasoning into the open.
- In England, ask for a review under Martha's Rule. It exists precisely for this situation: it gives patients and families the right to request an urgent review by a separate critical care team, independent of the ward team, when they are worried that someone is deteriorating and feel they are not being heard. Named after a girl who died of sepsis after her family's concerns were not escalated. Ask by name — the phrase is recognised and the mechanism is not discretionary where it has been implemented.
- Every UK hospital also has a Patient Advice and Liaison Service, and every trust has a route to escalate concern about a deteriorating patient. Using them during the admission is far more useful than complaining afterwards.
- If the person is deteriorating in front of you and nothing is happening, say so out loud to the nearest member of staff and keep saying it. This is uncomfortable and it is the correct thing to do.
The other half. Most fevers are viral, most people with an infection do not have sepsis, and the aim of everything above is not to obtain antibiotics — it is to have sepsis actively considered and excluded rather than never thought about. A clinician who has thought about it, examined for it and explained why this is not it has done the job; that answer is a good outcome, not a brush-off. What this section is against is the diagnosis never entering the room.
Meningitis
The classic triad — headache, neck stiffness, photophobia — is present in a minority of cases and is often absent in the very young and the very old.
| Age | What it actually looks like |
|---|---|
| Babies and toddlers | Fever with cold hands and feet, refusing feeds, vomiting, a high-pitched or moaning cry, irritability when handled, floppiness, a bulging fontanelle, unusual drowsiness. Neck stiffness is often absent |
| Children and adults | Severe headache, fever, vomiting, neck stiffness, dislike of bright light, confusion, drowsiness, seizures. Leg pain and cold extremities can precede everything else by hours |
| The rash, when it comes | Tiny red or purple pinpricks, spreading to blotches and bruise-like patches. Does not fade under a glass. Harder to see on darker skin — check the soles, palms, inside the eyelids, the roof of the mouth and the whites of the eyes |
What to do, and what not to wait for
- Call 999 on suspicion. Not after a rash appears, not after a GP appointment tomorrow. Say the word "meningitis" or "sepsis" — it changes the response.
- Deterioration can be measured in hours. Someone who was reviewed and sent home four hours ago and is now worse should be seen again. "They were checked this morning" is not reassurance in a condition that moves this fast.
- Say what has changed since the last assessment. The trajectory is more informative than the current numbers, and it is the thing a clinician most needs.
- Vaccination reduces the risk, and does not eliminate it. UK schedules cover several meningococcal groups and pneumococcus. A vaccinated child can still get meningitis, and "they've had their jabs" has delayed presentations.
Why this page pushes so hard in one direction. The site generally avoids one-sided framing. Here the asymmetry is real: the cost of over-calling is an assessment that finds a virus, and the cost of under-calling is measured in hours and organs. Where a condition can kill a well-looking person within a day, the position is not balance.