Recurring concern

Failure to provide timely and continuous treatment for oral thrush

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First reported 13 Aug 2018•Latest report 14 May 2024

Definition

What this concern includes

Includes failures in recognising, referring, prescribing, administering, continuing or reviewing clinically indicated treatment for oral thrush, including delays in treatment and failure to maintain treatment through discharge.

Not included

  • Excludes treatment delays or omissions involving other oral conditions unless oral thrush is the material safety concern.
  • Excludes generic medication, referral, staffing or documentation deficiencies unless they directly impair treatment of oral thrush.
  • Excludes oral-care, nutrition, swallowing or aspiration concerns where treatment of oral thrush is not the unsafe condition.
  • Excludes failures occurring after oral thrush has been adequately treated when the remaining issue concerns an unrelated downstream condition.
Reports
2

Distinct published reports

Individual concerns
2

A report can raise multiple concerns

Date range
2018–2024

First to latest report issue date

Stated actions
5

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.

Adelaide Medical Centre, London1
East Sussex Healthcare NHS Trust1
Lodge Care Home1
Royal Free London NHS Foundation Trust1

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. East Sussex

    AI-generated summary

    Carol Ann DIVALL · 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

    Carol Ann DIVALL had Alzheimer's disease and sustained a hip fracture at home on 15 September 2022, which was surgically repaired during a hospital admission. She was discharged on 24 October 2022 for end-of-life care and died at home on 29 October 2022. Concerns included severe oral thrush and malnutrition, limited mobilisation, development and deterioration of a grade 4 sacral pressure sore, and misleading or incomplete discharge documentation and investigation.

    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 provide and continue treatment for oral thrush

    Wider context from the report

    “A. That Mrs Divall developed severe oral thrush making it very difficult for her to eat and drink and take her oral medication. She was referred to the dietitians on 2.10.22 and triaged by an Assistant the following day. She was not prescribed Fortisip until 14.10.22 by which time she was becoming malnourished. The oral thrush continued until discharge. Nystatin appeared to be prescribed once on 12.10.22 and was not prescribed on discharge nor mentioned in the discharge summary. I heard evidence on PFD matters that software which requires a clinician to check oral care is being implemented. I remain of the opinion that this forms part of basic nursing care which was overlooked in Mrs Divall's case. ”

    Source location

    Carol Ann DIVALL · 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

    Implement electronic prescribing and medicines administration to reduce missed medicines.

    Verbatim wording from the response

    “We accept that the medical records show the prescription of Nystatin was not continued onto the next weekly paper medication chart when the previous one was full. We have recently introduced Electronic Prescribing & Medicines Administration (EPMA) system where the risk of a medication being missed is far reduced as the medication will stay on the system until the course is finished or stopped. We anticipate undertaking an audit of the new EPMA system within this financial year to review the impact on missed medication.”

    Source location

    Response from East Sussex Healthcare
    Page 2 · response
    Published 15 May 2024

    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

    Audit the impact of electronic prescribing and medicines administration on missed medication.

    Verbatim wording from the response

    “We accept that the medical records show the prescription of Nystatin was not continued onto the next weekly paper medication chart when the previous one was full. We have recently introduced Electronic Prescribing & Medicines Administration (EPMA) system where the risk of a medication being missed is far reduced as the medication will stay on the system until the course is finished or stopped. We anticipate undertaking an audit of the new EPMA system within this financial year to review the impact on missed medication.”

    Source location

    Response from East Sussex Healthcare
    Page 2 · response
    Published 15 May 2024

    Open published response

  2. Inner North London

    AI-generated summary

    Flora Marion BABER · 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

    Flora Marion Baber was admitted to the Royal Free Hospital from Compton Lodge Care Home on 25 January 2018 with increased confusion, slurred speech and difficulty breathing, and died there about a month later. Concerns included inadequate access to fluids, inappropriate food and eating assistance, delays in speech and language referral and treatment of oral thrush, an apparently sleeping staff member, inappropriate responses to toileting requests, and failure to record her opioid sensitivity across healthcare settings.

    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 treating oral thrush

    Wider context from the report

    “2. There was a delay in referring Dr Baber to the speech and language team and in treating her oral thrush. Most significantly, I heard evidence that it was only when family members pointed out a problem such as pain on swallowing, that staff acted to deal with this. ”

    Source location

    Flora Marion BABER · 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

    Appoint a nurse-qualified Clinical Services Manager to support medication audits and staff training across the homes.

    Verbatim wording from the response

    “vii) C&C have appointed a Clinical Services Manager who is nurse qualified and supports the Homes with medication audits and provides support and training for staff in this area.”

    Source location

    2018-0299-Response-by-CC-Housing-Trust
    Page 4 · response
    Published 24 January 2019

    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

    Review and further develop medication training with the Quality and Compliance Manager, Clinical Services Manager and Director of Workplace and Culture.

    Verbatim wording from the response

    “iii) The development of further medication training is currently under review with our Quality and Compliance Manager, the Clinical Services Manager and the Director of Workplace Culture. The review is due to be completed within the next 3 months. Training already includes a formal face to face training session with a comprehensive test at the end which requires a 100% pass rate. This is in addition to the online training programme”

    Source location

    2018-0299-Response-by-CC-Housing-Trust
    Page 5 · response
    Published 24 January 2019

    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

    Share learning on oral-thrush recognition and treatment with all medical staff on the ward.

    Verbatim wording from the response

    “However, ████████ has agreed to share the learning regarding thrush recognition and treatment with all medical staff on the ward.”

    Source location

    2018-0299-Response-by-Royal-Free-London-Hospitsl-NHS-Trust
    Page 4 · response
    Published 24 January 2019

    Open published response
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Data last updated 7 September 2026