Disease outbreak surveillance
40 items
2 sources
Insufficiently comprehensive or risk-based surveillance activities by APHA, leading to reduced capacity to detect new disease threats.
Cross-Source Insight
Disease outbreak surveillance has been flagged across 2 independent accountability sources:
17 inquiry recs
23 PFD reports
This issue has been identified by multiple independent accountability bodies, suggesting it is a recurring systemic concern.
Inquiry Recommendations (17)
F106 — Health Protection Agency Coordination and publication of providers' information on healthcare associated infections
Recommendation: The Health Protection Agency and its successor, should coordinate the collection, analysis and publication of information on each provider's performance in relation to healthcare associated infections, working with the Health and Social Care Information Centre.
Gov response: The government published "Hard Truths: the Journey to Putting Patients First" (Cm 8777) on 19 November 2013, responding to all 290 recommendations of the Francis Report. This followed an initial response "Patients First and Foremost" …
Accepted
F107 — Sharing concerns
Recommendation: If the Health Protection Agency or its successor, or the relevant local director of public health or equivalent official, becomes concerned that a provider's management of healthcare associated infections is or may be inadequate to provide sufficient protection of patients …
Gov response: The government published "Hard Truths: the Journey to Putting Patients First" (Cm 8777) on 19 November 2013, responding to all 290 recommendations of the Francis Report. This followed an initial response "Patients First and Foremost" …
Accepted
F108 — Support for other agencies
Recommendation: Public Health England should review the support and training that health protection staff can offer to local authorities and other agencies in relation to local oversight of healthcare providers' infection control arrangements.
Gov response: The government published "Hard Truths: the Journey to Putting Patients First" (Cm 8777) on 19 November 2013, responding to all 290 recommendations of the Francis Report. This followed an initial response "Patients First and Foremost" …
Accepted
COVID-M3.1 — IPC Structures and Transmission Risk
Recommendation: The UK government must ensure that there is a body (equivalent to the UK Infection Prevention and Control Cell) in place ready to be convened at the outset of any future pandemic, to consider and draft infection prevention and control …
Gov response: No formal response published by this government.
Unknown
COVID-M3.4 — Data Systems for High-Risk Individuals
Recommendation: The UK government, Scottish Government, Welsh Government and Northern Ireland Executive must ensure that health data and digital systems have the capability to identify individuals at high risk of morbidity or mortality from a pandemic disease quickly and accurately in …
Gov response: No formal response published by this government.
Unknown
COVID-M3.8 — Recording Healthcare Worker Deaths
Recommendation: The UK government, Scottish Government, Welsh Government and Northern Ireland Executive should work with their respective public health agencies and healthcare employers to develop nation-specific mechanisms to collect, analyse and publish data systematically on the deaths of healthcare workers in …
Gov response: No formal response published by this government.
Unknown
R16 — CDI outbreak reporting
Recommendation: Health Boards should ensure that the nurse in charge of each ward reports suspected outbreaks of CDI (as defined in local guidance) to the Infection Control Team.
Gov response: Section 2.1 of the Scottish Government's response highlights a robust HAI scrutiny regime across NHS Scotland, which drives improvements in infection control and prevention practices. The National Infection Prevention and Control Manual, introduced in January …
Accepted
R2 — HAI implementation strategy
Recommendation: Scottish Government should ensure that policies and guidance on healthcare associated infection are accompanied by an implementation strategy and that implementation is monitored.
Gov response: Section 2.1 of the Scottish Government's response highlights that Revised Healthcare Associated Infection (HAI) Standards were published in February 2015, which NHS boards will adopt from May 2015, with performance against them forming part of …
Accepted
R3 — IPC policy review
Recommendation: Health Boards should ensure that infection prevention and control policies are reviewed promptly in response to any new policies or guidance issued by or on behalf of the Scottish Government.
Gov response: Section 2.1 and 3.2 of the Scottish Government's response indicate that NHS boards are required to adhere to revised Healthcare Associated Infection (HAI) Standards and the National Infection Prevention and Control Manual, with performance against …
Accepted
R34 — Antimicrobial guidance implementation
Recommendation: Health Boards should ensure that changes in policy and/or guidance on antimicrobial practice issued by or on behalf of Scottish Government are implemented without delay.
Gov response: Section 2.1 of the Scottish Government's response outlines that the HAI Taskforce develops guidelines to improve antimicrobial prescribing practices, including an antimicrobial prescribing policy for Scotland and the Scottish Management of Antimicrobial Resistance Action Plan …
Accepted
R35 — Antibiotic prescribing monitoring
Recommendation: Scottish Government should monitor the implementation of policies and/or guidance on antibiotic prescribing issued in connection with healthcare associated infection.
Gov response: Section 2.1 of the Scottish Government's response details several mechanisms for monitoring the implementation of antibiotic prescribing policies. The HAI Taskforce established the Controlling Antimicrobial Resistance in Scotland Group to oversee activity and produce outcome …
Accepted
R4 — Local HAI Task Forces
Recommendation: Scottish Government should develop local healthcare Associated infection (HAI) Task Forces within each Health Board area.
Gov response: Section 2.1 of the Scottish Government's response states that the national Healthcare Associated Infection (HAI) Taskforce has been restructured into a smaller, more focused group. This group 'will work with local teams and existing structures …
Accepted
R40 — Prudent antibiotic prescribing
Recommendation: Health Boards should ensure that the key principles of prudent antibiotic prescribing are adhered to and that implementation of policy is rigorously monitored by management.
Gov response: Section 2.1 of the Scottish Government's response emphasizes the major role of prudent antibiotic prescribing in HAI prevention and control. The HAI Taskforce addresses this by developing guidelines, including an antimicrobial prescribing policy for Scotland …
Accepted
R53 — Surveillance systems fit for purpose
Recommendation: Health Boards should ensure that surveillance systems are fit for purpose, are simple to use and monitor, and provide information on potential outbreaks in real time.
Gov response: Section 2.1 of the Scottish Government's response details that national and local surveillance data are collected across a range of areas to support and monitor HAI policy, including data for HAI outbreaks. Section 4.2 further …
Accepted
R54 — Surveillance system training
Recommendation: Health Boards should ensure that the users of surveillance systems are properly trained in their use and fully aware of how to use and respond to the data available.
Gov response: Section 4.3 of the Scottish Government's response outlines national education and training initiatives, including a strategy from the HAI Taskforce to ensure all healthcare workers receive appropriate education and training related to HAI. This is …
Accepted
R55 — CDI reporting to CEO and Board
Recommendation: Health Boards should ensure that numbers and rates of CDI are reported through each level of the organisation up to the Chief Executive and the Board.
Gov response: Section 2.1 of the Scottish Government's response highlights that national surveillance of C. diff infection is conducted, and a specific C. diff infection target is included in Local Delivery Plan Standards, requiring NHS boards to …
Accepted
R71 — National CDI death monitoring
Recommendation: Scottish Government should identify a national agency to undertake routine national monitoring of deaths related to CDI.
Gov response: Section 2.1 notes the report's call for better national monitoring of HAI-related mortality, particularly C. diff deaths (recommendations 70 and 71). While the response details national and local surveillance data collection for HAI policy and …
Accepted
PFD Reports (23)
Chloe Ulett
Concerns: There is a lack of routine ammonia testing for acutely confused adults, and current RCEM guidelines for metabolic disorders are not well-embedded or sufficiently clear, especially for postpartum women.
Pending
Mia Lucas
Concerns: A lack of national guidance for clinicians on considering and diagnosing Autoimmune Encephalitis creates a risk of missed diagnoses and future deaths.
Response: The Royal College of Psychiatrists has established a national expert working group that has developed national guidance on the neuropsychiatric presentation of autoimmune encephalitis and autoimmune psychosis. This guidance is …
Response: The Department for Health and Social Care noted the concerns regarding national guidance for Autoimmune Encephalitis, but concluded that these are more appropriately addressed by NHS England, which will provide …
Responded
Edward Jones
Concerns: The absence of a nationally validated sepsis screening tool for Paediatric Emergency Departments and inconsistent application of the trust's own tool across units risk delayed sepsis diagnosis.
Response: NICE disputes the coroner's assertion that there is no validated sepsis screening tool for paediatric emergency departments, citing existing guidance and tools. They clarify their guidance focuses on suspected sepsis …
Responded
Wessam al Jundi
Concerns: Workers fabricating artificial stone are exposed to unsafe conditions with inadequate dust suppression and PPE, causing rapid onset of untreatable silicosis. Current surveillance is insufficient for this accelerated disease, risking future deaths.
Responded
Patricia Lines
Concerns: Outdated national guidance led to a nurse not cleaning skin before an injection, potentially increasing infection risk due to lack of disinfection and reliance on 20-year-old evidence.
Responded
Laura Farmer
Concerns: Public health authorities failed to adequately investigate a fatal E. coli source, neglecting to gather crucial family information or provide infection control advice. There was no feedback loop to clinicians, leaving the family without answers or safety guidance.
Responded
Carrianne Franks
Concerns: Inadequate TB exposure guidelines for healthcare professionals, overly narrow "close contact" definitions, insufficient staff education, and failures to include all staff in notifications for highly transmissible cases.
Responded
Kimberley Sampson and Samantha Mulcahy
Concerns: Unclear guidance on testing staff for potential infection sources and a lack of national protocols for antiviral therapy in post-partum women with systemic infection, specifically for Herpes Simplex, put patients at risk.
Responded
Sienna Barber
Concerns: Lack of national guidance for diagnosing and treating Group A Streptococcus, particularly for high-risk groups like children under 5, and the absence of rapid antigen testing for under 5s, creates diagnostic delays.
Responded
Alexandra Briess
Concerns: A critical lack of national systems for capturing and reporting anaphylaxis cases, especially fatal and near-fatal ones, along with no named accountability for allergy services, impedes understanding and prevention.
Overdue
Karen Starling and Anne Martinez
Concerns: Hospital water systems are contaminated with M abscessus, posing a serious risk to immunosuppressed patients. Existing water safety guidance is inadequate, lacking specific protocols for identifying and controlling mycobacteria in hospital settings.
Responded
Brian Mottram
Concerns: GPs' predominant use of telephone appointments potentially missed COVID-19 symptoms, and there were no clear tools to identify high-risk cases or trigger in-person assessments for vulnerable patients.
Responded
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
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
Zona Tebbs
Concerns: Critical clinical practice updates and medical guidance were not effectively communicated to primary care practitioners, leading to vital information being overlooked due to convoluted dissemination methods and outdated guidance.
Overdue
Tien Phung
Concerns: Strongyloides stercoralis, a treatable infection prevalent in certain regions, is not routinely screened for prior to transplant surgery. Its hyperinfection syndrome presents with non-specific symptoms, risking severe progression.
Overdue
Sebastian Clark
Concerns: The lack of a national screening program for streptococcal infection in labouring women misses opportunities to detect and treat infections like chorioamnionitis in infants.
Overdue
Natasha Ednan-Laperouse
Concerns: Pret-a-Manger had inadequate allergen labelling and no robust system to monitor allergic reactions. Additionally, Epipen's needle length and adrenaline dose were identified as dangerously insufficient for adult anaphylaxis.
Responded
Lauren Sandell
Concerns: Confusion persists regarding responsibility for vaccinating children not covered by school programs, and the optional nature of GP vaccination services means there's no audit to identify or protect unvaccinated children.
Responded
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
Ana Sirghi-Marin
Concerns: A guideline is needed for immediate microbiological analysis of discolored, non-purulent/non-blood-stained amniotic fluid samples. This precaution is vital for early infection detection, even if not immediately impactful.
Overdue
Terence Brooks
Concerns: The hospital misinterpreted Legionella test results and lacked a clear procedure for investigating outbreaks, leading to an erroneous conclusion about the infection source.
Overdue
Carla London
Concerns: Concerns were raised about the need to consider NICE guidance on late-onset sepsis in premature babies and to research infection monitoring systems to improve early detection and treatment.
Responded