Recurring concern

Failure of microbiology testing services to provide timely and reliable results

First to latest report 2 Mar 2017 — 5 Jun 2026

Reports that mention this concern
3
Times this concern has been raised
4
Stated actions linked to this concern
5

What this concern includes

Includes failures of the named microbiology testing service that impair timely and reliable results, including insufficient microbiologist capacity, delayed or omitted microbiology testing, unsuitable specimen collection or containers, laboratory processing delays and related result-availability controls.

What is not included
  • Excludes generic staffing or workforce shortages unless they directly impair the microbiology testing service.
  • Excludes clinical diagnosis or antibiotic-treatment decisions where no microbiology testing-service failure is identified.
  • Excludes non-microbiology diagnostic services and laboratory processes unrelated to providing microbiology results.
  • Excludes isolated documentation, communication or escalation deficiencies unless they directly impair timely or reliable microbiology testing or results.

Reports and published responses 3 reports

See individual reports that have raised this concern, and the actions taken in response

  1. West Sussex, Brighton and Hove

    AI-generated summary

    Mrs Mary (also known as Moira) Forlin · Prevention of Future Deaths report

    This summary was generated using AI from the published report. Please read the original report for the complete account.

    Report summary

    Mrs Mary Forlin was admitted to hospital after a fall at home with a long lie and was suffering from respiratory failure, likely driven by an infection of unknown source. She later collapsed and died from multiorgan failure arising from the infection and respiratory failure. The principal concerns were that clinicians did not actively follow guidance to review antibiotic treatment, microbiological testing was not undertaken early, and policies, systems and electronic records did not provide proactive checks or alerts to support infection testing, treatment and review when treatment was ineffective.

    Read the report on judiciary.uk

    Source evidence

    How this individual concern was interpreted

    PFD Monitor created a concise, searchable interpretation from the report wording shown below.

    PFD Monitor interpretation

    Failure to order microbiology tests promptly when antibiotics have no immediate effect

    Wider context from the report

    “Notwithstanding the existence of guidance, recommending review at 48-72 hours, and noting that this remains a live discussion topic at the Trust’s training sessions, it was apparent from the evidence heard, that clinicians did not actively consider or appear to follow the guidance, despite blood tests showing continuing signs of infection which broad spectrum antibiotics had not reduced. Nor were microbiology tests ordered early on when antibiotics had had no immediate effect; a missed opportunity confirmed in the evidence heard and which the medical witness suggested could, with hindsight, have been considered. Underlying these events, however, it is apparent that current policies, systems and processes – including electronic records – do not proactively flag, up, drive or require active consideration of tests, including whether and when results have been obtained, or whether further specialist tests should then be required, enabling more timely consideration as to whether targeted antibiotics should be administered, at urgency and pace where a patient remains patently unwell. Accepting that other actions iterated in the Trust’s recent submissions will reduce the risk of similar future deaths, there appear to be no obvious systemic checks and failsafes in patient care as regards infection testing, treatment and then review – especially where treatment is not working. ”

    Source location

    Mrs Mary (also known as Moira) Forlin · Prevention of Future Deaths report
    Page 3 · concerns

    Open source report

    Source evidence

    How this respondent action was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    Maintain microbiology systems for identifying deteriorating infection cases, escalating significant results, reviewing patients and coordinating specialist investigation and treatment advice.

    Verbatim wording from the response

    “Systems in place within the Microbiology Department to identify patients with infection, critically ill with infection, those at risk of or already deteriorating, ones with significant positive cultures, those that need changes to treatment or initiation and those that need discussion with regards to investigations or further microbiological samples:”

    Source location

    Response from University Hospitals Sussex NHS Foundation Trust
    Page 2 · response
    Published 13 August 2026

    Open published response

  2. Blackpool and the Fylde

    AI-generated summary

    Coral Amy O’Donnell · Prevention of Future Deaths report

    This summary was generated using AI from the published report. Please read the original report for the complete account.

    Report summary

    Coral Amy O’Donnell developed severe pneumonia after presenting with cough and cold-like symptoms and died in hospital on 17 May 2019 after prolonged intensive care. Concerns included failure to consider PVL Staphylococcus aureus promptly, limited awareness of relevant guidance and internal systems, problematic communication between critical care and microbiology teams, and insufficient microbiology staffing.

    Read the report on judiciary.uk

    Source evidence

    How this individual concern was interpreted

    PFD Monitor created a concise, searchable interpretation from the report wording shown below.

    PFD Monitor interpretation

    Insufficient microbiologist staffing capacity

    Wider context from the report

    “That the number of microbiologists at the time of Coral’s admission was limited – a senior Microbiologist told the court her team ought to comprise six microbiologists, but were limited to a maximum of four at the time and that remains the case. ”

    Source location

    Coral Amy O’Donnell · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

    Source evidence

    How this respondent action was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    Undertake a staffing review covering microbiologists and other infection-specialist roles.

    Verbatim wording from the response

    “The Trust is undertaking a staffing review, which takes into consideration the role of infection specialists of various categories, not only microbiology trained medics, but also Microbiologists, Infectious Diseases Physicians, PhD grade Antibiotic Pharmacists and Clinical Scientists with or without FRCPath.”

    Source location

    2021-0152-Response-from-Blackpool-Victoria-Hospital-Redacted
    Page 3 · response
    Published 18 May 2021

    Open published response

  3. Brighton and Hove

    AI-generated summary

    Paul William BARBER · Prevention of Future Deaths report

    This summary was generated using AI from the published report. Please read the original report for the complete account.

    Report summary

    Paul William BARBER had recently diagnosed aggressive lung cancer and developed pericarditis with fluid around his heart. Samples of the fluid were sent to microbiology in the wrong containers, causing a potential delay, and the identification of two organisms was not reported to clinicians until shortly after his death. The report identified these as failings, while stating that, on the balance of probabilities, they did not affect the outcome in this case.

    Read the report on judiciary.uk

    Source evidence

    How this individual concern was interpreted

    PFD Monitor created a concise, searchable interpretation from the report wording shown below.

    PFD Monitor interpretation

    Delays in reporting important microbiology results to clinicians

    Wider context from the report

    “(2) Delay in reporting important results to clinicians. On the 22nd July bacterial growth was detected in the bottles and gram staining showed gram positive cocci – this information was passed to the medical team looking after Mr Barber. On the next day, Saturday 23rd July, the laboratory found the same sample growing two organisms. This indicated that Mr Barber had a bacterial pericarditis – this was a very unusual situation and the identification of the organisms ought to have been given on the Saturday as soon as it was known to the medical team. For some reason the organisms were not reported until Tuesday 26th July shortly after Mr Barber’s death. Had these results been given appropriately on the 23rd July appropriate steps could have been taken to treat the patient with antibiotics. It is right to say that in this particular case on the balance of probabilities the two failings mentioned above did not affect the outcome – however it is right to report this so that these mistakes are highlighted and do not occur again either in this Hospital Trust or any other. ”

    Source location

    Paul William BARBER · Prevention of Future Deaths report
    Page 1 · concerns

    Open source report

    Source evidence

    How this individual concern was interpreted

    PFD Monitor created a concise, searchable interpretation from the report wording shown below.

    PFD Monitor interpretation

    Failure to send microbiology samples in the correct containers

    Wider context from the report

    “(1) Samples being sent to microbiology in the wrong containers and to elaborate on that Mr Barber had a recently diagnosed aggressive lung cancer on the back of which he developed pericarditis. By the 21st July 2016 it was clear that there was a collection of fluid around his heart which was susceptible to draining. This was done and sampling of the fluid was sent to the microbiologists for analysis. However, it was sent in the wrong container, this meant that it needed incubation before it could be dealt with giving a potential delay for results of between 24 – 48 hours. If it had been sent in the correct pot there is a good chance that full results would have been available the same day it was sent as the laboratory is open and testing until 7 p.m. ”

    Source location

    Paul William BARBER · Prevention of Future Deaths report
    Page 1 · concerns

    Open source report

    Source evidence

    How this respondent action was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    Discuss the delayed laboratory-result notification at a microbiology and infection clinical governance meeting as training for registrars prioritising urgent follow-up.

    Verbatim wording from the response

    “Concerning the delay in updating the clinicians caring for the patient about the new laboratory findings, the microbiology and infection department have discussed Mr Barber’s case in detail at their clinical governance meeting, as part of training for microbiology registrars to help them discriminate effectively in prioritising urgent follow up for appropriate specimens.”

    Source location

    Paul-Barber-Response
    Page 1 · response
    Published 4 August 2017

    Open published response

    Source evidence

    How this respondent action was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    Circulate Trust-wide guidance on submitting normally sterile body fluids in sterile white-capped containers rather than blood culture bottles.

    Verbatim wording from the response

    “In order to ensure that as many staff as possible learn from these events, a message has been circulated to all Trust staff reminding them that normally sterile body fluids, such as pericardial or ascitic fluid, should only be submitted to the laboratory in a sterile white capped container and not in a blood culture bottle. The same message made it clear that only blood and peritoneal dialysis fluid should be inoculated into blood culture bottles at the bedside. Secondly, the standard operating procedure within the laboratory has been altered so that, if such a specimen is received in the wrong container, an educational message is now sent advising on the correct container to be used in such circumstances so that the staff learn from this.”

    Source location

    Paul-Barber-Response
    Page 1 · response
    Published 4 August 2017

    Open published response

    Source evidence

    How this respondent action was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    Alter the laboratory standard operating procedure to send educational advice when specimens arrive in incorrect containers.

    Verbatim wording from the response

    “In order to ensure that as many staff as possible learn from these events, a message has been circulated to all Trust staff reminding them that normally sterile body fluids, such as pericardial or ascitic fluid, should only be submitted to the laboratory in a sterile white capped container and not in a blood culture bottle. The same message made it clear that only blood and peritoneal dialysis fluid should be inoculated into blood culture bottles at the bedside. Secondly, the standard operating procedure within the laboratory has been altered so that, if such a specimen is received in the wrong container, an educational message is now sent advising on the correct container to be used in such circumstances so that the staff learn from this.”

    Source location

    Paul-Barber-Response
    Page 1 · response
    Published 4 August 2017

    Open published response

Actions and positions describe what organisations say in published responses. Implementation is not independently verified.

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Data last updated 7 September 2026