Delayed patient infection risk notification
Inconsistent guidance leading to delayed notification of patients about infection risks from surgery (e.g., Mycobacterium Chimaera).
151 items
9 sources
3 inquiries
Strongest theme matches
Mixed across source types and ranked by classifier confidence plus text match strength.
PFD report
81match
Clinton Fear
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.
Matched on
terms: infection, patient
PFD report
77match
David Curry
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.
Matched on
terms: delayed, patient
PFD report
73match
Ibiyemi Ereoah
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.
Matched on
terms: delayed, patient
PFD report
73match
Kai Takagi
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.
Matched on
terms: delayed, patient
PFD report
69match
Gordon Arthur
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.
Matched on
terms: infection, patient
PFD report
69match
Tom Cribley
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.
Matched on
terms: delayed, patient
PFD report
69match
Peter Knight
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.
Matched on
terms: delayed, patient
PFD report
69match
Nicholas Winterton
The nationally recognized risk level for Mycobacterium Chimaera infection is inaccurate and outdated, leading to inadequate informed consent and a low threshold of suspicion among clinicians.
Matched on
terms: infection
PFD report
69match
Rita Flynn
A patient was discharged home with clear indicators of infection before blood test results were available, contrary to best practice.
Matched on
terms: infection, patient
PFD report
69match
Sara Jones
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.
Matched on
terms: delayed, patient
PFD report
69match
Terence Hines
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.
Matched on
terms: infection, patient
PFD report
61match
Peter Smith
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.
Matched on
terms: patient
PFD report
61match
Leslie Harris
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.
Matched on
terms: patient
PFD report
61match
Gillian Stokes
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.
Matched on
terms: patient
PHSO casework decision
60match
P-002750 - Maidstone and Tunbridge Wells NHS Trust
Mr R complains the Trust did not correctly monitor his cystic fibrosis related infection and delayed putting in place an antibiotic treatment plan between December 2022 and February 2023.
Matched on
terms: delayed, infection
PFD report
57match
Craig White
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.
Matched on
terms: patient
PFD report
57match
Shannon Gee
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.
Matched on
terms: patient
PFD report
57match
George Taylor
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.
Matched on
terms: patient
PFD report
57match
James Bateley
Nursing homes and community nurses face significant delays in accessing essential wound dressings, as orders through GPs can take weeks, impacting patient care.
Matched on
terms: patient
PFD report
57match
Raymond Edwards
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.
Matched on
terms: delayed
PFD report
57match
Tomas Kelly
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.
Matched on
terms: infection
PFD report
57match
Edna Collett
A patient remained in hospital unnecessarily for over two months due to the inability to secure a suitable social care placement, impacting bed availability.
Matched on
terms: patient
PFD report
57match
Prabhaker Kapoor
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.
Matched on
terms: delayed
PFD report
57match
Brenda Elmer
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.
Matched on
terms: patient
PFD report
57match
Roger Phelps
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.
Matched on
terms: patient
PFD report
57match
Christopher Collinson
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.
Matched on
terms: patient
PFD report
57match
Natasha Adams
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.
Matched on
terms: patient
PFD report
57match
Trevor Reynolds
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.
Matched on
terms: patient
PFD report
57match
Angela Maguire
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.
Matched on
terms: delayed
PFD report
57match
Akash Bhudia
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.
Matched on
terms: patient
PFD report
57match
Helen Coogan
Missing qFIT test results for a patient with prolonged abdominal symptoms indicate a potential systemic issue requiring investigation, especially given the cause of death.
Matched on
terms: patient
PFD report
57match
Maria Shafighian
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.
Matched on
terms: patient
PFD report
57match
Ethel Reed
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.
Matched on
terms: patient
PFD report
57match
Malcolm Taylor
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.
Matched on
terms: patient
PFD report
57match
Lee Armstrong
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.
Matched on
terms: patient
PFD report
57match
Khadija Kerri
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.
Matched on
terms: patient
PFD report
57match
Gareth Tatchell
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.
Matched on
terms: patient
PFD report
57match
Leslie Thompson
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.
Matched on
terms: patient
PFD report
57match
Nicola Mulliss
A lack of policy for microbiological swabbing during wound re-suturing meant a Staphylococcus Aureus infection was not detected early, delaying crucial treatment.
Matched on
terms: infection
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
PHSO casework decision
56match
P-002002 - University Hospitals Birmingham NHS Foundation Trust
Mr Y complains about the care the Trust gave to his mother. He complains Mrs Y got a second infection while an inpatient at the Trust and staff did not tell him. He also complains it did not reply to his complaint.
Matched on
terms: infection, patient
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
51match
P-001516 - The Royal Wolverhampton NHS Trust
Mrs I complains about the care her father received from the Trust after he was admitted to hospital. She says Trust staff did not correctly follow the cross-infection guidelines which meant her father caught COVID-19 from another patient, and subsequently died.
Matched on
terms: infection, patient
PHSO casework decision
51match
P-003445 - Warrington and Halton Hospitals NHS Foundation Trust
Ms R complains about the care and treatment Warrington and Halton NHS Foundation Trust provided to her in August 2023. She says there was no continuity of care during her labour and staff failed to prevent her getting an infection and delayed recognising and treating it.
Matched on
terms: delayed, infection
LGO / SPSO decision
50match
201400264 - Highland NHS Board
Ms C, an advocate, complained on behalf of her client (Mr A) about the infection control procedures used by Raigmore Hospital when he had a total hip replacement. When Mr A attended the pre-operative assessment when he was first scheduled for surgery, it was found that he had an in-growing toenail and surgery was delayed until this was...
Matched on
terms: delayed, infection
PFD report
49match
Jack Hurn
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.
Matched on
classifier match
Inquiry recommendation
48match
R37 - CDI senior assessment and treatment
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.
Matched on
terms: patient
Inquiry recommendation
48match
IBI-8a - Pre-1996 Transfusion Testing
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.
Matched on
terms: patient
PHSO casework decision
48match
P-003770 - Doncaster and Bassetlaw Teaching Hospitals NHS Foundation Trust
Mrs C complained about the care and treatment of her adult son when he was admitted to hospital in November 2022. She complains doctors failed to give him antibiotics in a timely way even though he was admitted with a known infection.
Matched on
terms: infection