Dear Mr Crooks

Thank you for your letter of 4th September 2025 following the inquest of NICOLA MULLISS, in which you issued a regulation 28 report to prevent future deaths.

The matter of concern you identified was:

‘In evidence I was told that had a swab been taken for microbiological analysis when the wound was re-sutured, it was possible that the Staphylococcus Aureus infection could have been detected at this earlier juncture and treatment instigated before the infection spread and resulted in the fatal staphylococcal meningitis. However, I was told that it is not policy / guidance for such testing to be undertaken so this did not occur.’

Our response:

I would like to express our condolences to the family of Miss Mulliss. I am grateful for your observations and we are committed to learning from this case to strengthen patient safety and clinical practice.

Having reviewed your comments, we can confirm that it is not clinically appropriate to take swabs of all leaking wounds. Wounds leak for a number of reasons, frequently as a result of the natural healing process. Serous or haemoserous fluid leaks (as occurred

2 in this case) are common, and part of the inflammation associated with all wounds. They are not indicative of infection. Like healthy skin, post operative wounds are seldom sterile and microorganisms can be isolated from all wounds whether they are infected or not. Isolating organisms does not always mean that the patient requires antibiotic treatment and unnecessary use of antibiotics can lead to increased antimicrobial resistance which is a global threat to health.

Staph aureus colonisation in the skin is common in the normal population, estimated to be around 1 in 3 people, although this can vary in different age groups or health risk factors. For certain procedures it is important to mitigate the risk of these and other organisms from causing infection by ensuring asepsis of the surgical field, administering prophylactic antibiotics among other measures. This is recognised by national and international guidelines (NICE, WHO, CDC, and other professional bodies).

Following your correspondence, I can confirm that we will strengthen our pathways to ensure that when a patient is suspected of having an infection, appropriate cultures are undertaken in a timely manner, including wound swabs and that where clinically appropriate, patients are commenced promptly on antibiotics. Compliance with these standards is regularly monitored, and we will also consider additional ways to strengthen these safeguards.

I hope this response reassures you that we are taking these issues very seriously and are constantly seeking to further improve our standards in this important area.