Recurring concern

Failure to obtain clinically indicated microbiological samples

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First reported 27 Nov 2013•Latest report 1 Sep 2016

Definition

What this concern includes

Includes failures of the dedicated microbiological sampling process where a clinically abnormal fluid, wound or other specimen should have been sampled for culture, swab or comparable microbiological analysis, including failures arising from absent or inadequate guidance.

Not included

  • Excludes delays or errors in laboratory analysis after an appropriate sample has been obtained.
  • Excludes generic diagnostic, documentation, staffing or communication deficiencies unless they directly result in failure to obtain a clinically indicated microbiological sample.
  • Excludes routine sampling failures where no clinically abnormal specimen or infection-related indication is identified.
  • Excludes non-microbiological testing, including histology, unless the report also explicitly identifies a microbiological sampling failure.
Reports
3

Distinct published reports

Individual concerns
3

A report can raise multiple concerns

Date range
2013–2016

First to latest report issue date

Stated actions
0

Described in published responses

Reports over time

Reports over time

Reports about this concern issued each year.

* 2026 is projected from reports observed to 7 Sep 2026.

Most frequent recipients

Most frequent recipients

Reports about this concern sent to each recipient.

Betsi Cadwaladr University LHB1
British Maternal And Fetal Medicine Society1
Glan Clwyd Hospital1
Guy'S and St Thomas' NHS Foundation Trust1
Royal College of Obstetricians and Gynaecologists1

Concerns and responses across reports

Only concerns grouped under this recurring concern are included. Select any concern, action or position to view the source wording.

  1. Inner North London

    AI-generated summary

    Ana Geanina SIRGHI-MARIN · 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

    Ana Geanina Sirghi-Marin died on 29 July 2016 from Escherichia coli sepsis associated with a naturally occurring uterine infection while sixteen weeks pregnant, after undergoing amniocentesis. The principal concern was that unusually dark yellow, non-blood-stained amniotic fluid was not sent for immediate microbiological analysis and promptly followed up, despite the absence of fever or another infection indicator at the time.

    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 obtain immediate microbiological analysis of unusually discoloured amniotic fluid

    Wider context from the report

    “The amniotic fluid drawn off at amniocentesis two days before death was neither purulent nor blood stained, but was discoloured dark yellow. Given the rarity of such non blood stained discolouration, I heard evidence that it would be a wise precaution in this situation always to send a sample for immediate microbiological analysis, and quickly to follow up the result. I say always because, at the time of the amniocentesis, there was no fever or other indicator of infection, yet when Ms Sirghi-Marin presented at the emergency unit the following afternoon she was very unwell, and she died the next morning. Such action would not have changed the outcome in this instance, because presentation to the emergency unit took place approximately 26 hours after the amniocentesis. However, it might in another case. And given the rarity of such non blood stained discoloured amniotic fluid, a guideline that this action is necessary does not seem onerous. ”

    Source location

    Ana Geanina SIRGHI-MARIN · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

    Source evidence

    How this respondent position was interpreted

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

    PFD Monitor interpretation

    The Royal College of Obstetricians and Gynaecologists is responsible for considering the recommendations in guideline revision and website guidance.

    Verbatim wording from the response

    “We have discussed your recommendations with the joint chair of the Royal College of Obstetricians & Gynaecologists’ Guidelines Committee.”

    Source location

    2017-0005-Response-by-Royal-College-of-Obstetricians-Gynaecologists
    Page 1 · response
    Published 19 February 2017

    Open published response

  2. North Wales (East and Central)

    AI-generated summary

    Sally Ellison · 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

    Sally Ellison contracted legionella while on holiday in Tunisia in mid-May 2012 and died on 1 June 2012 from cardiac arrest, multi-organ failure and legionella pneumonia. Concerns were raised that testing for legionella was not undertaken until 31 May, with confirmation on 1 June, and that this may have delayed optimal treatment; the report also identified the need for earlier testing and a rapid testing and reporting service.

    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 undertake timely urine testing for legionella

    Wider context from the report

    “1. That although it was clear upon her admission to Glan Clwyd on the 29th of May 2012 at around 16.00 hours, that she was suffering from a severe form of Community Acquired Pneumonia, and that this was recognised as being an atypical pneumonia that same evening, no urine sample was sent for analysis until overnight on the 31st of May with the confirmation of it being positive for legionella coming on the morning of the 1st of June. It is the case that treatment was already being given for the possibility of legionella from the 30th of May, but this was not against a confirmed diagnosis and therefore optimal treatment may have been delayed. ”

    Source location

    Sally Ellison · Prevention of Future Deaths report
    Page 1 · concerns

    Open source report

  3. Eastern District of London

    AI-generated summary

    Peter Jeffrey · 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

    Peter Jeffrey collapsed at home and died on 10 February 2013 after developing a swollen, infected left leg and foot. The report raised concerns that, after scans did not reveal DVT, no effective alternative diagnosis or treatment was considered, and that the open blister was not cultured or swabbed and intravenous antibiotics were not considered. The inquest concluded that the left foot ulcer was not tested and consequently went untreated.

    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

    Lack of microbiological sampling from open blister wounds

    Wider context from the report

    “2. No culture was taken for testing from the open blister which was full of pus. 3. No swab was taken. ”

    Source location

    Peter Jeffrey · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

    Source evidence

    How this respondent position was interpreted

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

    PFD Monitor interpretation

    The records show no open blister or pus on 17 August 2012, so there was nothing to swab.

    Verbatim wording from the response

    “Please see above for the primary detail. We agree that in the event of an ‘open blister’ being noted, which included pus or signs of infection, it would be appropriate to expect the necessary organisms to be collected on a swab and then grown and tested in the laboratory.”

    Source location

    2013-0313-Response-by-Guys-St-Thomas-NHS-Foundation-Trust
    Page 3 · response
    Published 22 February 2014

    Open published response
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Data last updated 7 September 2026