Residents who are harder to assess

Sepsis can be missed when someone cannot easily describe symptoms. NICE advises extra care when taking a history is difficult, including for people with communication challenges, cognitive impairment, learning disabilities, neurodiversity, severe mental health conditions, brain injury or if English is a second language.

What "extra care" looks like in practice

• Know the baseline: how the person usually shows pain, fear, tiredness, thirst or discomfort.
• Listen to families and regular staff: they may spot subtle changes before observations become clearly abnormal.
• Use reasonable adjustments: communication aids, interpreters, easy-read material, quiet spaces, familiar staff or more time.
• Watch function: sudden loss of walking, eating, drinking, continence, participation or cooperation can be a warning sign.
• Check skin colour carefully: cyanosis, mottling or pallor can be harder to see on darker skin; check palms, soles, lips, tongue, gums, nail beds and inside eyelids.
• Do not dismiss behaviour: agitation, withdrawal or irritability can indicate illness, pain, delirium or fear.

NICE also identifies being from an ethnic minority background as a factor that may increase the risk of sepsis or delayed recognition. This requires careful assessment, attention to possible bias and communication barriers, and awareness of how signs present on different skin tones.

Management controls

The more difficult it is for someone to describe symptoms, the more important baseline knowledge and careful observation become.