Recurring concern
Failure to provide timely antibiotic treatment for suspected or confirmed infection
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Request correctionFirst reported 8 Oct 2013•Latest report 7 Feb 2026
What this concern includes
Includes failures to recognise the need for, initiate, provide or maintain clinically indicated antibiotic treatment for suspected or confirmed infection, including delayed commencement, omitted treatment, avoidable gaps and failure to provide alternative treatment when antibiotics are withheld.
Not included
- Excludes antibiotic prophylaxis where the concern is prevention of infection rather than treatment of suspected or confirmed infection.
- Excludes failures limited to sepsis recognition, diagnostic investigation or escalation when antibiotic treatment provision is not itself deficient.
- Excludes antimicrobial prescribing or selection concerns where treatment was provided promptly and the issue is only clinical appropriateness.
- Excludes generic medication supply, staffing, communication or documentation deficiencies unless they directly cause delayed, omitted or interrupted antibiotic treatment.
- Reports
- 15
- Individual concerns
- 15
- Date range
- 2013–2026
- Stated actions
- 13
Distinct published reports
A report can raise multiple concerns
First to latest report issue date
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.
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.
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Concerns raised1
Failure to provide timely intravenous fluids and antibiotics to ambulance-held patients with suspected infection
This report raised 2 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concernsEach statement is shown once, even when linked to more than one concern.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.3
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Position
The Care Quality Commission will provide a separate response to the concerns.
Stated by Department of Health and Social Care
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Position
The internal review found no evidence that CQC advised the trust not to treat patients remaining on ambulances.
Stated by Care Quality Commission -
Position
Providing operational clinical advice about where or how specific patients should be treated falls outside CQC’s remit.
Stated by Care Quality Commission
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Concerns raised1
Failure to trigger sepsis six and provide required antibiotics when indicated
This report raised 1 other concern. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concernsEach statement is shown once, even when linked to more than one concern.
Actions described in response An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.7
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Action
Share the patient’s story with AMU staff, focusing on neutropenic sepsis, hypothermia and the sepsis six bundle.
Stated by Royal Cornwall Hospitals NHS Trust -
Action
Convene an AMU educational awayday focused on sepsis and the deteriorating patient.
Stated by Royal Cornwall Hospitals NHS Trust -
Action
Increase compliance with sepsis training to 80% within four months and 90% within six months, excluding staff on leave.
Stated by Royal Cornwall Hospitals NHS Trust
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Action
Maintain mandatory sepsis training for nurses and healthcare assistants as statutory and essential training.
Stated by Royal Cornwall Hospitals NHS Trust -
Action
Provide sepsis update lunchtime training sessions for doctors.
Stated by Royal Cornwall Hospitals NHS Trust -
Action
Apply the sepsis screening tool to all blood pressure machines.
Stated by Royal Cornwall Hospitals NHS Trust -
Action
Develop a sepsis alert within the new e-Care system to digitally flag when the sepsis six should be actioned.
Stated by Royal Cornwall Hospitals NHS Trust
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Concerns raised1
Failure to put alternative treatments in place when antibiotics are withheld
This report raised 7 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concernsEach statement is shown once, even when linked to more than one concern.
Actions described in response An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.1
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Action
Use microbiology management-plan stickers in patient notes when clinicians are unavailable during microbiology review.
Stated by Tameside and Glossop Integrated Care NHS Foundation Trust
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1
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Position
The hospital is responsible for considering the operational concerns and reporting the actions and improvements it will take.
Stated by Department of Health and Social Care
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Concerns raised1
Delays in commencing antibiotics for infected haematoma
This report raised 3 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concernsEach statement is shown once, even when linked to more than one concern.
No linked response statementsNo respondent-stated action or position is linked to these concerns in the published data.
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Concerns raised1
Delays in administering prescribed antibiotics
This report raised 2 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concernsEach statement is shown once, even when linked to more than one concern.
Actions described in response An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.2
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Action
Develop and deliver an SBAR handover training programme for all neonatal intensive care nursing and medical staff.
Stated by the Queen Elizabeth Hospital, King'S Lynn, NHS Foundation Trust -
Action
Debrief staff involved in the delayed antibiotic communication.
Stated by the Queen Elizabeth Hospital, King'S Lynn, NHS Foundation Trust
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Concerns raised1
Failure to initiate antibiotic treatment promptly for suspected fatal infection
This report raised 1 other concern. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concernsEach statement is shown once, even when linked to more than one concern.
Actions described in response An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.2
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Action
Re-audit sepsis performance against Sepsis 6 standards and address identified practice gaps through governance monitoring.
Stated by Lewisham and Greenwich NHS Trust -
Action
Remind clinical staff to administer prescribed critical medications within one hour and reinforce this through ward and team meetings.
Stated by Lewisham and Greenwich NHS Trust
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1
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Position
The Trust states antibiotics were administered within an hour, disputing that Amikacin administration timing was unconfirmed or late.
Stated by Lewisham and Greenwich NHS Trust
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Concerns raised1
Delays in the administration of antibiotics
This report raised 3 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concernsEach statement is shown once, even when linked to more than one concern.
No linked response statementsNo respondent-stated action or position is linked to these concerns in the published data.
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Concerns raised1
Delays in initiating prescribed intravenous fluids and antibiotic treatment
This report raised 1 other concern. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concernsEach statement is shown once, even when linked to more than one concern.
No linked response statementsNo respondent-stated action or position is linked to these concerns in the published data.
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Concerns raised1
Failure to provide timely and appropriate antibiotics
This report raised 7 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concernsEach statement is shown once, even when linked to more than one concern.
Actions described in response An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.1
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Action
Provide ongoing Sepsis training on the Sepsis 6 bundle and NEWS documentation, escalation and implementation to medical and nursing staff.
Stated by Cwm Taf Morgannwg University Local Health Board
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Concerns raised1
Failure to consider alternative antibiotic administration routes when cannulation is unsuitable
This report raised 5 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concernsEach statement is shown once, even when linked to more than one concern.
No linked response statementsNo respondent-stated action or position is linked to these concerns in the published data.
Data last updated 7 September 2026