Delayed patient infection risk notification
57 items
2 sources
Inconsistent guidance leading to delayed notification of patients about infection risks from surgery (e.g., Mycobacterium Chimaera).
Cross-Source Insight
Delayed patient infection risk notification has been flagged across 2 independent accountability sources:
7 inquiry recs
50 PFD reports
This issue has been identified by multiple independent accountability bodies, suggesting it is a recurring systemic concern.
Inquiry Recommendations (7)
IBI-8a — Pre-1996 Transfusion Testing
Recommendation: When doctors become aware that a patient has had a blood transfusion prior to 1996, that patient should be offered a blood test for Hepatitis C.
Gov response: Implemented across all four nations. Healthcare providers directed to offer Hepatitis C testing to patients who received transfusions before 1996.
Accepted
Delivered
IR2-2 — Eligibility Conditions for Infected Persons
Recommendation: I recommend that the conditions of eligibility for admission of relevant infected persons to the scheme should be that: a) they have been diagnosed as being infected with one or more of HCV (including natural clearers who have suffered loss), …
Gov response: In accordance with recommendations 1 and 2 of the Second Interim Report, the Government is clear that both those who have been infected and affected by this scandal are eligible for compensation and is compensating …
Accepted
Delivered
PENROSE-1 — HCV Testing for Pre-1991 Transfusion Recipients
Recommendation: The Scottish Government takes all reasonable steps to offer an HCV test to everyone in Scotland who had a blood transfusion before September 1991 and who has not been tested for HCV.
Gov response: No formal government response published. Scottish Government established Short-Life Working Group with Health Protection Scotland and Scottish National Blood Transfusion Service to implement testing programme.
Accepted
Delivered
R37 — CDI senior assessment and treatment
Recommendation: Health Boards should ensure that any patient with suspected CDI receives full clinical assessment by senior medical staff, that specific antibiotic therapy for CDI is commenced timeously.
Gov response: Section 4.1 of the Scottish Government's response acknowledges that recommendation 37 addresses delays in diagnosing and treating C. diff infection. Section 2.1 details that Scotland's Health Protection Network published C. diff guidance, revised in 2014, …
Accepted
R41 — Laboratory specimen processing
Recommendation: Health Boards should ensure that there is no unnecessary delay in processing laboratory specimens, in reporting positive results and in commencing specific antibiotic treatment.
Gov response: Section 3.2 of the Scottish Government's response highlights that NHS board antimicrobial management teams (AMTs) drive comprehensive approaches to education on antimicrobial stewardship for clinical staff and promote application of antimicrobial policies. Section 4.2 details …
Accepted
R63 — Effective CDI patient isolation
Recommendation: 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.
Gov response: Section 3.1 of the Scottish Government's response addresses patient isolation through the requirement for all planned new-build hospitals to provide 100% single-room accommodation, and refurbished builds at least 50%. This measure significantly reduces the risk …
Accepted
R65 — Isolation for infectious diarrhoea
Recommendation: Health Boards should ensure that appropriate steps are taken to isolate patients with potentially infectious diarrhoea.
Gov response: Section 2.1 of the Scottish Government's response details the Standard Infection Control Precautions (SICPs), which are basic measures to reduce the risk of germ transmission. Among the 10 SICPs is "Patient placement in wards and …
Accepted
PFD Reports (50)
Nicola Mulliss
Concerns: A lack of policy for microbiological swabbing during wound re-suturing meant a Staphylococcus Aureus infection was not detected early, delaying crucial treatment.
Responded
Leslie Thompson
Concerns: A lack of evening and weekend physiotherapy services in hospitals causes discharge delays, leaving medically fit patients exposed to unnecessary risks within the acute hospital environment.
Responded
Gareth Tatchell
Concerns: Persistent delays in cancer diagnostic, staging, and treatment pathways, especially for staging scans, are adversely affecting patient survivability rates and prognoses, making treatable cancers irresectable.
Responded
Khadija Kerri
Concerns: The hospital lacked a clear policy for disseminating addendum radiology reports from external providers to the treating clinical team, causing critical delays in identifying and treating a patient's fractures.
Responded
Lee Armstrong
Concerns: Emergency call systems fail to solicit or share existing medical conditions with ambulance call handlers, who also lack access to patient records, risking inadequate responses for patients, particularly those with conditions causing confusion.
Responded
Malcolm Taylor
Concerns: A persistent national shortage of available mental health beds, despite ongoing efforts, means patients identified as high-risk are left awaiting critical care, posing a risk of future deaths.
Responded
Gillian Stokes
Concerns: Insufficient clinical guidance for diagnosing radiation-induced sarcoma in breast implant patients and an inadequate 5-year surveillance period. A crucial follow-up appointment after an aspiration was also not carried out.
Responded
David Curry
Concerns: A critical surgery for an obstructed kidney was delayed by five months due to lack of NHS theatre capacity, increasing the patient's sepsis risk, leading to the patient seeking private care and subsequently dying from sepsis.
Responded
Ethel Reed
Concerns: Newly opened hospital wards suffered from peripatetic staffing and lack of leadership, hindering patient care and concern escalation. Additionally, electronic patient records failed to track author changes on discharge letters, risking miscommunication.
Overdue
Terence Hines
Concerns: Failures in hospital cleaning protocols led to a patient acquiring MRSA from a previously occupied room. Multiple failures to perform routine MRSA screening before and during his inpatient stay also contributed to a fatal infection.
Responded
Kai Takagi
Concerns: Critical abnormal blood results were not communicated to a discharged patient due to a failure in the hospital's call-back system and informal handover process between shifts, leading to delayed care.
Overdue
Clinton Fear
Concerns: Current guidelines inconsistently notify patients of Mycobacterium Chimaera infection risk only for post-January 2013 surgeries, despite earlier evidence, potentially delaying diagnosis and harming patients from prior procedures.
Overdue
Akash Bhudia
Concerns: Significant and unexpected X-ray findings indicative of tuberculosis were not promptly highlighted to the referring clinician because the patient had been discharged. There is no clear process for alerting referrers to such critical changes in non-inpatient cases.
Responded
Helen Coogan
Concerns: Missing qFIT test results for a patient with prolonged abdominal symptoms indicate a potential systemic issue requiring investigation, especially given the cause of death.
Responded
Maria Shafighian
Concerns: An inefficient internal postal system for communication between departments caused significant delays in escalating urgent changes in a patient's condition, specifically dysphagia, to the relevant team.
Responded
Sara Jones
Concerns: A patient transfer occurred without a radiologist's report, which was then delayed in transmission and subsequently not acted upon by receiving doctors, highlighting a critical lack of protocol for radiology report delivery.
Responded
Rita Flynn
Concerns: A patient was discharged home with clear indicators of infection before blood test results were available, contrary to best practice.
Responded
Trevor Reynolds
Concerns: The health board experienced significant delays in fully implementing a new Standard Operating Procedure for irregular scan reports and auditing its effectiveness, allowing known patient risks to continue.
Responded
Natasha Adams
Concerns: A patient's care level was downgraded without adhering to policy, and a crucial audit to ensure compliance for other patients is facing significant, unacceptable delays.
Responded
Christopher Collinson
Concerns: A manual patient allocation system risks unassessed patients, and the electronic prescribing system lacks a secondary check, increasing the danger of incorrect medication being administered.
Responded
Roger Phelps
Concerns: Delays exceeding 48 hours for COVID-19 swab results allowed asymptomatic infectious patients to spread the virus on non-COVID wards, a risk potentially unresolved in other trusts.
Overdue
Nicholas Winterton
Concerns: The nationally recognized risk level for Mycobacterium Chimaera infection is inaccurate and outdated, leading to inadequate informed consent and a low threshold of suspicion among clinicians.
Overdue
Norma Bradbury
Concerns: A significant delay in the hospital discharge letter reaching the GP led to a missed timely review of medication and blood pressure, causing a gap in essential post-discharge care.
Overdue
Leslie Harris
Concerns: The Trust misinterpreted Public Health England guidance, exposing vulnerable patients to COVID-19 by moving them to isolation wards. Concerns remain as the unamended guidance might lead other trusts to similar unsafe practices.
Responded
Joan Sanderson
Concerns: The provided text details the deceased's medical history and cause of death but does not articulate specific coroner's concerns regarding future deaths.
Overdue
Brenda Elmer
Concerns: Discharged patients were not effectively informed about a hospital-acquired Listeria outbreak, delaying diagnosis. Additionally, there are no legal requirements for private labs or hospitals to share Listeria isolates, hindering timely outbreak identification.
Responded
Ibiyemi Ereoah
Concerns: Insufficient gynae-oncology consultant cover led to a lack of advocacy in MDT meetings and delayed consultant reviews. There was no system to ensure timely consultant intervention for patients deemed unfit for surgery.
Overdue
Peter Smith
Concerns: Significant delays in diagnosing and treating adenocarcinoma, caused by sequential rather than concurrent medical processes, rendered planned surgery impossible and contributed to the patient's death.
Responded
Thiago Araujo
Concerns: The provided concerns text is incomplete, preventing a proper summary of the identified safety issues.
Responded
Prabhaker Kapoor
Concerns: Essential updates to safer swallowing training and the MOODLE package were significantly delayed and lacked a completion timeline, despite being recommended in a Root Cause Analysis report.
Responded
Peter Knight
Concerns: The Trust significantly delayed completing and implementing a crucial policy for transferring oxygen-dependent patients. New documentation was produced, but trials had not even commenced by the agreed deadline.
Responded
Tom Cribley
Concerns: Repeated systemic failings included poor documentation, delayed escalation of patient deterioration and NMEWS, inadequate clinical handovers, and delayed administration of crucial antibiotics for sepsis, issues previously identified by CQC.
Overdue
Dylan Hill
Concerns: A critical lack of communication procedures meant a previous non-fatal anaphylactic reaction at a food business was not reported to Trading Standards, preventing timely regulatory action and risking future deaths.
Responded
Edna Collett
Concerns: A patient remained in hospital unnecessarily for over two months due to the inability to secure a suitable social care placement, impacting bed availability.
Overdue
Tomas Kelly
Concerns: Parents of a child with Down Syndrome were not adequately informed of their child's increased infection risks, and routine chickenpox vaccination for this vulnerable group should be considered.
Responded
Patricia Parker
Concerns: Numerous sedation guidelines are not widely known by clinicians, highlighting a need for better training and awareness of sedation risks, especially in the elderly.
Overdue
Raymond Edwards
Concerns: A critical lack of a reliable system for disseminating histology results to named consultants meant crucial diagnostic information was not promptly reviewed, posing a significant risk of delayed diagnosis and treatment in future cases.
Responded
Gordon Arthur
Concerns: The absence of clear policies for requesting and communicating results of investigative tests to consultants led to critical delays in diagnosing and treating a patient's infection, risking future harm.
Responded
Alan Stead
Concerns: Delays in taking and testing blood samples from prisoners at HMP Dovegate were identified, which could have serious clinical consequences.
Responded
Sally Ellison
Concerns: There was a significant delay in conducting diagnostic tests for severe pneumonia, specifically Legionella, hindering confirmed diagnosis and potentially delaying optimal treatment. A rapid testing and reporting service is urgently needed.
Responded
James Bateley
Concerns: Nursing homes and community nurses face significant delays in accessing essential wound dressings, as orders through GPs can take weeks, impacting patient care.
Responded
Mary Marshall
Concerns: A general lack of awareness among hospital staff and GPs about the importance of GDH positive results, which indicate Clostridium Difficile vulnerability, risks inappropriate antibiotic prescribing.
Responded
Shannon Gee
Concerns: Delays in mental health treatment occurred due to unaddressed gaps between organisational treatment thresholds and difficulties transferring medical notes, raising concerns about seamless patient care.
Overdue
George Taylor
Concerns: A significant number of patients are being sent out of county monthly due to an ongoing lack of acute psychiatric beds, posing a clear risk of future deaths.
Responded
Jackson Chadd
Concerns: Concerns include inadequate supervision for junior paediatric staff, insufficient consultant oversight for out-of-hours admissions, failure to apply national guidelines for fever in children, and disregarding parental concerns.
Overdue
Robert Jones
Concerns: CT scan results were not made available promptly to relevant departments, nor were they acted upon without delay and within a reasonable timeframe.
Responded
Afifa Qaisar
Concerns: Critical issues included inaccurate drug administration records, missing emergency equipment, delays in urgent platelet transfusions, and a failure to properly monitor fluid balance, indicating systemic clinical procedural shortcomings.
Overdue
Craig White
Concerns: Concerns include insufficient TB screening protocols before Infliximab treatment, inadequate prescriber awareness of increased TB risk, and the need for better patient education and prompt treatment for suspected tuberculous meningitis.
Overdue
Jack Hurn
Concerns: The hospital lacked official guidance for managing VITT, causing staff unawareness of time-critical transfer needs and incorrect specialist consultations, despite available national and regional pathways.
Responded
Angela Maguire
Concerns: The absence of a regional system to share radiology images across hospitals led to missed opportunities for comparative analysis, risking missed diagnoses and delayed palliative care discussions.
Overdue