Delayed patient infection risk notification
Inconsistent guidance leading to delayed notification of patients about infection risks from surgery (e.g., Mycobacterium Chimaera).
Strongest theme matches
Mixed across source types and ranked by classifier confidence plus text match strength.
PFD report
93match
Clinton Fear
The coroner raises concerns about the inconsistency between NHS guidance for notifying patients of Mycobacterium Chimaera infection risk (from January 2013) and evidence of infections occurring significantly earlier, which may lead to delayed diagnosis and harm for affected patients.
Matched on
terms: delayed, infection, patient
PFD report
85match
Joan Sanderson
The coroner noted the absence of a routine MRSA swab on hospital admission for certain patient groups, which delayed the early identification of infection. This practice could impact outcomes in cases requiring emergency surgery with postoperative infection.
Matched on
terms: delayed, infection, patient
PFD report
73match
Leslie Harris
The coroner raised concerns regarding the interpretation of Public Health England guidance on patient movement to Covid-19 isolation wards, noting that varied interpretations across trusts could put vulnerable patients at risk of infection.
Matched on
terms: infection, patient
PFD report
73match
Sara Jones
The coroner identified an absence of a protocol for prompt and secure radiology report delivery. This meant a patient's CT scan report was delayed and unconfirmed after transfer, leading to doctors not following up on potential bowel injury signs.
Matched on
terms: delayed, patient
PFD report
69match
Brenda Elmer
The coroner raised concerns about the lack of communication to out-of-area hospital patients regarding a Listeria outbreak, which delayed diagnosis. They also noted no legal requirement for private labs or hospitals to share Listeria isolates, impeding early outbreak identification.
Matched on
terms: delayed, patient
PFD report
69match
Roger Phelps
The coroner noted concerns about delays in COVID-19 swab results for inpatients, which led to asymptomatic infectious patients remaining on non-Covid wards and potentially spreading infection. It was unclear if this issue had been resolved by other trusts, meaning the risk might remain.
Matched on
terms: infection, patient
PFD report
69match
Natasha Adams
The coroner noted a patient's care level was downgraded without following trust policy, and an audit to check broader compliance with this policy had been significantly delayed.
Matched on
terms: delayed, patient
PFD report
69match
Rita Flynn
The coroner noted that the patient was discharged from the hospital with indicators of infection before blood test results were available, which was contrary to best practice.
Matched on
terms: infection, patient
PFD report
69match
Nicola Mulliss
The absence of a policy for microbiological wound swabs during re-suturing potentially delayed infection detection and treatment, which could have prevented fatal staphylococcal meningitis.
Matched on
terms: delayed, infection
PFD report
65match
Nicholas Winterton
The coroner notes that Public Health England's nationally recognised risk for Mycobacterium Chimaera infection is inaccurate, based on outdated 2017 data and underreporting, impacting informed consent and timely diagnosis. An immediate review and update of this statistical data is required.
Matched on
terms: infection
PFD report
61match
Tomas Kelly
Concerns were raised regarding the inconsistent provision of information to parents of children with Down Syndrome about their increased infection risks, and the need to consider routine chickenpox vaccination for this group.
Matched on
terms: infection
PFD report
61match
Edna Collett
The coroner noted delays in discharging patients who were medically fit for discharge, specifically due to difficulties in securing suitable social placements, leading to prolonged hospital stays.
Matched on
terms: patient
PFD report
61match
Jack Hurn
The coroner noted a lack of official Trust guidance on managing VITT, which led to delays in transferring the patient to a specialist centre and contacting appropriate consultants, despite national and regional guidance being available.
Matched on
terms: patient
PFD report
61match
Terence Hines
The coroner identified the absence of a required "Red clean" for a room previously occupied by a patient with MRSA before Mr. Hines' transfer, alongside the omission of routine MRSA screenings that should have occurred during his prolonged inpatient stay and prior to surgery.
Matched on
terms: patient
PFD report
61match
David Curry
The coroner noted a significant delay in Mr Curry's urgent surgery due to a lack of theatre capacity, which resulted in a prolonged stent dwell time and an increased risk of post-operative urinary infection and sepsis.
Matched on
terms: infection
PFD report
61match
Gillian Stokes
The coroner identified insufficient clinical guidance on radiation-induced sarcoma and first-line investigations for breast implant patients, noting the 5-year surveillance period is shorter than the condition's 10-year latency. There were also concerns that a hospital's 2-week post-aspiration review protocol was not followed.
Matched on
terms: patient
Inquiry recommendation
60match
R41 - Laboratory specimen processing
Health Boards should ensure that there is no unnecessary delay in processing laboratory specimens, in reporting positive results and in commencing specific antibiotic treatment. Infection control staff should carry out regular audits to ensure that there are no unnecessary delays in the management of infected patients once the diagnosis is confirmed.
Matched on
terms: infection, patient
HSSIB recommendation
60match
Failures in communication or follow-up of unexpected significant radiological findings
It is recommended that NHSX develops a method of digitally notifying patients of results. This should be used to inform patients of unexpected significant radiological findings after an agreed timeframe. It should be developed in conjunction with the Royal College of Radiologists. The notification system should be tested and evaluated.
Matched on
terms: notification, patient
CQC action
60match
William Harvey Hospital
The trust must ensure staff comply with infection control and prevention procedures when looking after patients with or suspected of having an infectious illness
Matched on
terms: infection, patient
PHSO casework decision
60match
P-002750 - Maidstone and Tunbridge Wells NHS Trust
The Trust allegedly failed to monitor Mr R's infection and delayed antibiotic treatment for his cystic fibrosis, which negatively impacted his physical health.
Matched on
terms: delayed, infection
PHSO casework decision
60match
P-003477 - A practice in the Wiltshire area
Mr O complained the Trust failed to identify rib fractures and provide antibiotics, leading to pain and a hip infection. He also complained about poor family communication and the Practice's delayed response to his injuries.
Matched on
terms: delayed, infection
PFD report
57match
Craig White
The coroner noted concerns regarding protocols for pre-Infliximab tuberculosis screening, the awareness of healthcare professionals about TB risk, and the need for ongoing patient education. Additionally, prompt treatment initiation for suspected tuberculous meningitis was highlighted.
Matched on
terms: patient
PFD report
57match
Afifa Qaisar
The coroner identified issues with inaccurate drug administration records, unavailability of resuscitation equipment, the patient not being notified to the RMO, delays in platelet transfusions, and a lack of fluid balance charting.
Matched on
terms: patient
PFD report
57match
Robert Jones
The coroner identified that CT scan results should be made promptly available to all departments involved in patient care, and appropriate action should be taken without delay and within a reasonable timescale.
Matched on
terms: patient
PFD report
57match
George Taylor
The coroner noted the undesirable practice of sending 8 to 12 psychiatric patients out of county monthly due to a lack of acute beds, identifying a risk that this could lead to a future death.
Matched on
terms: patient
PFD report
57match
Sally Ellison
The coroner noted a delay in sending a urine sample for legionella analysis despite early recognition of atypical pneumonia, which may have delayed optimal treatment. Concerns were also raised regarding the lack of a rapid testing and reporting service for legionella.
Matched on
terms: delayed
PFD report
57match
Raymond Edwards
The coroner noted a lack of a reliable system or protocol for disseminating histology results to the named consultant, especially after patient discharge. This could lead to delays in diagnosis and treatment of serious conditions.
Matched on
terms: patient
PFD report
57match
Tom Cribley
The coroner raised concerns about the lack of a systematic and monitored training programme for clinical staff in sepsis identification and treatment. This is crucial given recurring issues identified in documentation, timely escalation of patient deterioration, and handovers.
Matched on
terms: patient
PFD report
57match
Peter Knight
The coroner noted delays in the completion and trial of a new policy for transferring oxygen-dependent patients, which was not finalised by the agreed deadline following the inquest.
Matched on
terms: patient
PFD report
57match
Ibiyemi Ereoah
Insufficient gynae-oncology consultant cover at Newham University Hospital hindered patient advocacy and oversight. The coroner also noted the absence of a system for timely consultant reviews, and that previously agreed actions to address these issues had not been completed.
Matched on
terms: patient
PFD report
57match
Norma Bradbury
The coroner notes concerns regarding delays in GPs receiving discharge letters, deeming a three-day delay unacceptable when timely follow-up is required, as such delays risk impacting patient outcomes.
Matched on
terms: patient
PFD report
57match
Christopher Collinson
The coroner noted that the patient allocation system required manual checks, meaning patients could be missed for assessment, and the electronic prescribing system lacked a secondary check for medication selection, risking incorrect medication administration.
Matched on
terms: patient
PFD report
57match
Trevor Reynolds
The coroner noted delays in fully implementing a new Standard Operating Procedure for managing irregular scan reports and a lack of an audit process to ensure its effectiveness, which allows known risks to patients to continue.
Matched on
terms: patient
PFD report
57match
Angela Maguire
The coroner highlighted the absence of a regional system for sharing radiology images between West London hospitals, which hinders image comparison and increases clinician workload, with potential for missed diagnoses and adverse patient outcomes.
Matched on
terms: patient
PFD report
57match
Akash Bhudia
The coroner noted a lack of process to ensure significant, unexpected changes in follow-up X-rays, especially those highly suggestive of tuberculosis, are highlighted to referring clinicians in a timely manner for discharged patients.
Matched on
terms: patient
PFD report
57match
Maria Shafighian
The coroner noted concerns regarding the hospital's internal postal system for urgent notifications between teams, as there was no process to ensure urgent matters were brought to attention immediately or that mail was dealt with in a timely manner.
Matched on
terms: notification
PFD report
57match
Kai Takagi
The coroner identified gaps in tracking and following up A&E patients with outstanding test results after discharge, noting reliance on un-auditable oral handovers and incomplete implementation of abnormal result reviews.
Matched on
terms: patient
PFD report
57match
Ethel Reed
Inadequate staffing, leadership, and patient escalation pathways were identified on wards opened for winter pressures. The electronic patient system also fails to record the author of discharge letter changes, risking miscommunication and treatment delays.
Matched on
terms: patient
PFD report
57match
Malcolm Taylor
The coroner identified an insufficient number of mental health beds available at Norfolk and Suffolk NHS Trust to meet patient need, despite actions taken by the trust. This persistent shortage was also noted as a national problem.
Matched on
terms: patient
PFD report
57match
Lee Armstrong
The NHS Pathways system does not prompt for existing conditions, and information from 111 online is not shared with NWAS. Call handlers also lack access to patient medical records, which may lead to crucial medical history not being known during emergency calls.
Matched on
terms: patient
PFD report
57match
Khadija Kerri
Doncaster Royal Infirmary has no clear internal policy for disseminating addendum reports or their information from external radiology services to the treating clinical team, risking delays and incorrect patient management.
Matched on
terms: patient
PFD report
57match
Leslie Thompson
The coroner noted that the lack of evening and weekend physiotherapy services in the hospital caused discharge delays, exposing patients who were medically fit but awaiting assessment to unnecessary risks in an acute hospital environment.
Matched on
terms: patient
Committee recommendation
56match
#45 - Third Report - Coronavirus: lessons learned to date
The discharge of elderly people from NHS hospitals into care homes without having been tested at the beginning of the pandemic—while understandable as the NHS prepared to accept a surge of covid patients—had the unintended consequence of contributing to the spread of infection in care homes. The seeding of infections also happened as a result of staff entering...
Matched on
terms: infection, patient
Committee recommendation
56match
#45 - Sixth Report - Coronavirus: lessons learned to date
The discharge of elderly people from NHS hospitals into care homes without having been tested at the beginning of the pandemic—while understandable as the NHS prepared to accept a surge of covid patients—had the unintended consequence of contributing to the spread of infection in care homes. The seeding of infections also happened as a result of staff entering...
Matched on
terms: infection, patient
CQC action
56match
Queen Elizabeth The Queen Mother Hospital
The trust must ensure staff comply with infection control and prevention procedures when looking after patients with or suspected of having an infectious illness
Matched on
terms: infection, patient
PHSO casework decision
56match
P-002002 - University Hospitals Birmingham NHS Foundation Trust
Mr Y complained his mother, Mrs Y, acquired a second infection as an inpatient and staff failed to inform him. He also criticised the Trust's complaint handling for not answering his questions.
Matched on
terms: infection, patient
PHSO casework decision
55match
P-003445 - Warrington and Halton Hospitals NHS Foundation Trust
Ms R complained about lack of continuity of care during labour, failure to prevent infection, and delayed treatment, leading to her and her daughter contracting sepsis.
Matched on
terms: delayed, infection
Inquiry recommendation
53match
R63 - Effective CDI patient isolation
Health Boards should ensure that there is effective isolation of any patient who is suspected of suffering from CDI, and that failure to isolate is reported to senior management.
Matched on
terms: patient
PHSO casework decision
52match
P-003770 - Doncaster and Bassetlaw Teaching Hospitals NHS Foundation Trust
Mrs C complained the Trust delayed giving her son, D, intravenous antibiotics for a UTI, leading to his rapid deterioration and death, believing this affected his survival chances.
Matched on
terms: delayed
PHSO casework decision
52match
P-002553 - Stockport NHS Foundation Trust
Nurses failed to clean his wound after surgery, leading to severe infection, forcibly removed his surgical drain, and wrongly told him he had cancer.
Matched on
terms: infection