Recurring concern

Failure to provide indicated antibiotic prophylaxis

First to latest report 4 Sep 2013 — 22 Jan 2024

Reports that mention this concern
6
Times this concern has been raised
9
Stated actions linked to this concern
10

What this concern includes

Includes failures to recognise, recommend, prescribe or provide antibiotic prophylaxis when it is specifically indicated for a procedure, infection risk or patient vulnerability, including the anchor's gastrointestinal-surgery prophylaxis concern and peri-operative prophylaxis for MRSA risk.

What is not included
  • Excludes therapeutic antibiotic delays or omissions where the concern is treatment of an established or suspected infection rather than prophylaxis.
  • Excludes prophylaxis involving non-antibiotic medicines, such as anticoagulants or antivirals.
  • Excludes generic prescribing, clinical-knowledge or guideline deficiencies unless they directly result in failure to recognise or provide indicated antibiotic prophylaxis.
  • Excludes antibiotic-prophylaxis concerns limited to an unrelated named pathway when no failure of the prophylaxis control itself is asserted.

Reports and published responses 6 reports

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

  1. Teesside and Hartlepool

    AI-generated summary

    Kate Elizabeth 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

    Kate Elizabeth O’Donnell underwent surgery on 16 March 2022 and was discharged the following day. She developed sepsis from the surgery, originating in her gut, and died at James Cook University Hospital on 23 March 2022. Principal concerns included inadequate surgical planning, failure to provide appropriate prophylactic antibiotics for the gastrointestinal surgery, insufficient postoperative vigilance and assessment before discharge, incomplete nursing records, and inadequate discharge information.

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    Source evidence

    How this individual concern was interpreted

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

    PFD Monitor interpretation

    Incorrect prescribing of prophylactic antibiotics after urology surgery

    Wider context from the report

    “2. The consultant urologist did not know the results of pre-surgery urine test results and subsequently prescribed incorrect prophylactic antibiotics post urology surgery. ”

    Source location

    Kate Elizabeth O’Donnell · Prevention of Future Deaths report
    Page 3 · 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 recognise the recommendation for prophylactic antibiotics in gastro-intestinal surgery

    Wider context from the report

    “3. The consultant urologist was not aware of the classification of surgeries and didn’t know that surgery could be clean-contaminated. He did not know of the SIGN guidelines and that prophylactic antibiotics were highly recommended for this type of gastro-intestinal surgery. ”

    Source location

    Kate Elizabeth O’Donnell · Prevention of Future Deaths report
    Page 3 · 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 provide prophylactic antibiotics for gastro-intestinal surgery

    Wider context from the report

    “4. The consultant urologist overlooked the provision of prophylactic antibiotics for the gastro-intestinal surgery. ”

    Source location

    Kate Elizabeth O’Donnell · 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

    Complete an antimicrobial-guidance compliance audit and share its findings with the relevant clinical collaborative.

    Verbatim wording from the response

    “An audit of compliance with Trust antimicrobial guidance has been undertaken within the Digestive Diseases, Urology and General Surgery Services Collaborative throughout February 2024, which has identified areas for improvement in relation to antimicrobial prescribing. Detailed findings of the audit will be shared with the Collaborative in early April 2024, and this clinical risk will also be discussed within the Clinical Policy Group in April 2024, which is attended by senior Clinical Leaders from across the Trust.”

    Source location

    Response from South Tees Hospitals
    Page 3 · response
    Published 25 January 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

    Update the Adult Antimicrobial Policy with links to the MicroGuide Antibiotic Prescribing Guidelines app.

    Verbatim wording from the response

    “The Trust’s Adult Antimicrobial Policy will be updated by the end of April 2024 to include links to the MicroGuide Antibiotic Prescribing Guidelines app, which is a tool used to publish and provide easy access to local antimicrobial guidelines, to facilitate timely access to advice of effective and safe treatment of infections.”

    Source location

    Response from South Tees Hospitals
    Page 3 · response
    Published 25 January 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

    Create electronic drug order sets for standardised first- and second-line surgical prophylactic antibiotic prescribing.

    Verbatim wording from the response

    “Additionally, the Trust Pharmacy team will create specific drug order sets within the recently implemented Electronic Prescribing and Medicines Administration (ePMA) system, to support standardised and structured prescribing for first and second line prophylactic antibiotics following surgery. This will be completed by the end of April 2024.”

    Source location

    Response from South Tees Hospitals
    Page 3 · response
    Published 25 January 2024

    Open published response

    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

    SIGN guidance is not necessarily applicable because it is Scottish; clinicians are expected to follow the Trust’s NICE-aligned antimicrobial policy.

    Verbatim wording from the response

    “The Trust’s Adult Antimicrobial Policy reflects NICE guidance (2020), which recognises the need for prophylactic antibiotics following the completion of surgery involving clean-contaminated wounds, involving the genitourinary or alimentary tracts. As SIGN guidelines are Scottish, these are not necessarily applicable, and we would expect our clinicians to be aware of, and apply, NICE rather than SIGN guidance.”

    Source location

    Response from South Tees Hospitals
    Page 2 · response
    Published 25 January 2024

    Open published response

  2. Cornwall and Isles of Scilly

    AI-generated summary

    Theresa Mary Thompson · 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

    Theresa Mary Thompson died on 9 October 2016 after admission with sepsis caused by a Streptococcus pneumonia infection, following a history of splenectomy and recent ventriculo-peritoneal shunt insertion. Concerns were raised that she was not receiving lifelong antibiotic prophylaxis and had no antibiotic cover for the shunt procedure, and that there was no evidence she had been advised or prescribed antibiotics before or after the procedure.

    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 antibiotic prophylaxis cover for medical procedures in patients after splenectomy

    Wider context from the report

    “At the inquest, the pathologist advised that Streptococcus pneumonia infections were typical for patients having undergone splenectomy. The spleen was an important immune defence organ for this type of bacteria. Usually patients were given a vaccination to prevent this type of disease and life-time antibiotic prophylaxis. Both the Pathologist and Treating clinician at the time of death, expressed concerns to the inquest that Mrs Thompson was not on prophylaxis antibiotics and that she had no antibiotic prophylaxis cover for her recent procedure especially as the Streptococcus infection was Serum type 6C for which there was no currently available pneumococcal vaccines (Reference report from Public Health England, Colindale, The Respiratory and Vaccine Preventable Bacteria Reference Unit (RVPBRU)). The GP gave evidence that Mrs Thompson had been advised about inoculation and taking life-long antibiotic prophylaxis but at some point had declined (although there were no written records to support his evidence in her medical note). There was no evidence that she was advised or prescribed antibiotics prior to or after her Ventriculo-Peritoneal Shunt procedure in August 2016 at Kings College Hospital. The family acknowledged that a number of the family had had a splenectomy due to familial Acholuric Jaundice but they were unsure that the family members appreciated the necessity for inoculation or prophylaxis antibiotics. They were concerned that there were mixed messages being given out by the Health Agencies about the use of antibiotics and the need to not overuse antibiotics and this had led to them not being inoculated or accepting life time prophylaxis antibiotics or the necessity of cover during medical procedures (if they had been advised at all). ”

    Source location

    Theresa Mary Thompson · Prevention of Future Deaths report
    Page 2 · 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 ensure life-long antibiotic prophylaxis for patients after splenectomy

    Wider context from the report

    “At the inquest, the pathologist advised that Streptococcus pneumonia infections were typical for patients having undergone splenectomy. The spleen was an important immune defence organ for this type of bacteria. Usually patients were given a vaccination to prevent this type of disease and life-time antibiotic prophylaxis. Both the Pathologist and Treating clinician at the time of death, expressed concerns to the inquest that Mrs Thompson was not on prophylaxis antibiotics and that she had no antibiotic prophylaxis cover for her recent procedure especially as the Streptococcus infection was Serum type 6C for which there was no currently available pneumococcal vaccines (Reference report from Public Health England, Colindale, The Respiratory and Vaccine Preventable Bacteria Reference Unit (RVPBRU)). The GP gave evidence that Mrs Thompson had been advised about inoculation and taking life-long antibiotic prophylaxis but at some point had declined (although there were no written records to support his evidence in her medical note). There was no evidence that she was advised or prescribed antibiotics prior to or after her Ventriculo-Peritoneal Shunt procedure in August 2016 at Kings College Hospital. The family acknowledged that a number of the family had had a splenectomy due to familial Acholuric Jaundice but they were unsure that the family members appreciated the necessity for inoculation or prophylaxis antibiotics. They were concerned that there were mixed messages being given out by the Health Agencies about the use of antibiotics and the need to not overuse antibiotics and this had led to them not being inoculated or accepting life time prophylaxis antibiotics or the necessity of cover during medical procedures (if they had been advised at all). ”

    Source location

    Theresa Mary Thompson · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

  3. Manchester North

    AI-generated summary

    baby Dominic Smith · 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

    Baby Dominic Smith was born on 2 June 2015 after a prolonged labour and died at approximately 18 hours of life following a collapse. The report describes pneumonia as the cause of death and identifies concerns including failure to recognise possible rupture of membranes and infection risk, inadequate maternal and neonatal observations, failure to escalate deterioration, delayed antibiotic treatment, and communication and record-keeping problems.

    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 routinely offer intrapartum prophylactic antibiotics to women with current or previous positive GBS tests

    Wider context from the report

    “Department of Health, NIHCE and the Royal Colleges: 1. I previously completed a PFD 13 month ago in relation to a neonatal GBS death. At that time I raised the following concerns: - That antenatal screening for GBS was not being routinely offered by the NHS to all pregnant women during the final weeks of pregnancy, - That prophylaxis intrapartum antibiotics were not routinely offered to all women who test positive for GBS (or have done so in the past) & - That given the seriousness of the illness, in the absence of a national screening and prophylactic treatment programme, babies were potentially being put at risk of harm/death. During the course of the inquest into Baby Smith’s death the evidence suggested that no further action has been taken in this regard, despite the responses received in relation to the last PFD action. I therefore raise the issues again as a concern. ”

    Source location

    baby Dominic Smith · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

  4. Mid Kent and Medway

    AI-generated summary

    Alwyn Ann Head · 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

    Alwyn Ann Head was admitted to hospital after falls caused a fractured femur at the site of a prosthesis. She underwent surgery, developed an MRSA wound infection, deteriorated after further surgery, and died on 20 August 2015. Concerns included failure to establish her MRSA history, lack of prophylactic Teicoplanin, absence of a post-operative wound care plan, inadequate evidence of wound inspection, and meaningless nursing documentation about the wound.

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    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 prophylactic Teicoplanin when indicated by MRSA risk

    Wider context from the report

    “(2) Prophylactic Teicoplanin was not provided pre- or post-operatively even though the results of an MRSA screen would not have been available at the time of surgery (MRSA –ve written on pre-op form erroneously) ”

    Source location

    Alwyn Ann Head · 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

    Update orthopaedic antimicrobial guidelines to clarify prophylaxis for patients with unknown MRSA status.

    Verbatim wording from the response

    “We have recognised the importance of ensuring that MRSA status is checked and appropriate antibiotic regime applied. The orthopaedic antimicrobial guidelines have been updated to provide more clarity over the prophylaxis for patients with unknown MRSA status.”

    Source location

    A-head-Response
    Page 2 · response
    Published 23 March 2016

    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

    Amend the surgical safety checklist to verify MRSA status and history with patients and staff before induction and at theatre sign-in.

    Verbatim wording from the response

    “The surgical safety checklist is being amended to ensure MRSA status and MRSA History is verified by two staff and with the patient pre operatively in the Anaesthetic Room before induction and again with the whole theatre team at ‘sign in’.”

    Source location

    A-head-Response
    Page 2 · response
    Published 23 March 2016

    Open published response

  5. Manchester North

    AI-generated summary

    Baby Olsberg · 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

    Baby Olsberg was born on 23 December 2013 and developed worsening symptoms in the hours after birth. Despite medical treatment and transfer to tertiary care, he suffered three cardiac arrests and died on 24 December 2013; blood cultures confirmed GBS infection. The concerns identified were the lack of routine antenatal GBS screening and routine prophylactic intrapartum antibiotics, and the resulting potential risk of serious harm or death to babies.

    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 routinely offer prophylactic intrapartum antibiotics to women with current or previous positive GBS tests

    Wider context from the report

    “2. That prophylactic intrapartum antibiotics are not routinely offered to all women who test positive for GBS (or have done so in the past). ”

    Source location

    Baby Olsberg · 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

    Encourage research into the clinical and cost effectiveness of intrapartum antibiotic prophylaxis guided by routine antenatal GBS screening.

    Verbatim wording from the response

    “You may also be interested in our clinical guideline on Antibiotics for early-onset neonatal infection (CG149, 2012). The guideline provides a framework outlining risk factors and clinical indicators that may be used to direct antibiotic management decisions. Once again, we have encouraged further research into the clinical and cost effectiveness of intrapartum antibiotic prophylaxis targeting group B streptococcus and guided by routine antenatal screening. Further information is available on our website at: www.nice.org.uk/CG149.”

    Source location

    2015-0177-Response-by-N.I.C.E
    Page 2 · response
    Published 7 May 2015

    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

    Publish and maintain guidance on preventing early-onset neonatal Group B streptococcal disease.

    Verbatim wording from the response

    “The 2nd edition of the RCOG Green top guideline number 36, Prevention of Early-onset Neonatal Group B Streptococcal Disease was published on 1st July 2012. It gives guidance based on the recommendations of the National Screening Committee.”

    Source location

    2015-0177-Response-by-Royal-College-of-Obstetricians-and-Gynaecologists
    Page 1 · response
    Published 7 May 2015

    Open published response

    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

    Current evidence does not support intrapartum antibiotics for women whose GBS carriage was detected only during a previous pregnancy.

    Verbatim wording from the response

    “Current evidence does not support screening for GBS or the administration of IAP to women in whom GBS carriage was detected in a previous pregnancy.”

    Source location

    2015-0177-Response-by-Royal-College-of-Obstetricians-and-Gynaecologists
    Page 2 · response
    Published 7 May 2015

    Open published response

  6. Leicester City and South Leicestershire

    AI-generated summary

    Karen Lesley SUTTON · 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

    Karen Lesley Sutton, who had primary antibody deficiency disorder and had undergone a splenectomy, was readmitted on 11 October 2012 with severe sepsis and died that evening after cardiac arrest. Concerns included the Immunology team not being notified of her hospital admissions, discontinuation of her prophylactic antibiotics on discharge, and inadequate arrangements for follow-up and communication between departments.

    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 prophylactic antibiotic medication at discharge

    Wider context from the report

    “(1) Not withstanding her 12 year history of regular Immunology follow-up, the team were not notified of her admission to hospital , on either occasion during August and September 2012, and thus given the opportunity to have input into her care and her discharge. (2) Mrs Sutton was discharged home without prophylactic antibiotic medication (3) Mrs Sutton was left to arrange her next out patient appointment and it was fortuitous that ████████ was able to see her after the day of discharge, 4th October 2012. (4) ████████ was unaware of any Trust policy to share admissions between departments. He acknowledged this as a Learning point and although he has personally instigated a practice to encourage patients and /or their relatives to let his department know of any admissions, this is neither robust or in some circumstances practical and cannot be relied upon as a means of communication Trust-wide. ”

    Source location

    Karen Lesley SUTTON · 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

    Explore ward-based technicians’ knowledge of prophylactic antibiotics required after splenectomy.

    Verbatim wording from the response

    “In addition as a result of your second concern our Chief Pharmacist will explore the current level of knowledge of ward-based technicians on prophylactic antibiotics post splenectomy. This case will be discussed at clinical meetings on all three Trust sites to discuss systems and processes that can be implemented to ensure that drugs that must continue on discharge can be flagged and clearly communicated. Both of these actions will be concluded by the end of November 2013. This case will be discussed at the Trust’s Medicines Management Board in December 2013. In addition the junior doctors involved in the care of Mrs Sutton will be particularly reminded about the importance of fully considering pre-admission medication.”

    Source location

    2013-0223-Response-by-University-Hospitals-of-Leicester
    Page 2 · response
    Published 4 September 2013

    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

    Discuss systems and processes across all three Trust sites for flagging and communicating medicines that must continue after discharge.

    Verbatim wording from the response

    “In addition as a result of your second concern our Chief Pharmacist will explore the current level of knowledge of ward-based technicians on prophylactic antibiotics post splenectomy. This case will be discussed at clinical meetings on all three Trust sites to discuss systems and processes that can be implemented to ensure that drugs that must continue on discharge can be flagged and clearly communicated. Both of these actions will be concluded by the end of November 2013. This case will be discussed at the Trust’s Medicines Management Board in December 2013. In addition the junior doctors involved in the care of Mrs Sutton will be particularly reminded about the importance of fully considering pre-admission medication.”

    Source location

    2013-0223-Response-by-University-Hospitals-of-Leicester
    Page 2 · response
    Published 4 September 2013

    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

    Remind the junior doctors involved to fully consider patients’ pre-admission medication.

    Verbatim wording from the response

    “In addition as a result of your second concern our Chief Pharmacist will explore the current level of knowledge of ward-based technicians on prophylactic antibiotics post splenectomy. This case will be discussed at clinical meetings on all three Trust sites to discuss systems and processes that can be implemented to ensure that drugs that must continue on discharge can be flagged and clearly communicated. Both of these actions will be concluded by the end of November 2013. This case will be discussed at the Trust’s Medicines Management Board in December 2013. In addition the junior doctors involved in the care of Mrs Sutton will be particularly reminded about the importance of fully considering pre-admission medication.”

    Source location

    2013-0223-Response-by-University-Hospitals-of-Leicester
    Page 2 · response
    Published 4 September 2013

    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