Recurring concern

Failure to provide timely antibiotic treatment for suspected or confirmed infection

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First reported 8 Oct 2013•Latest report 7 Feb 2026

Definition

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

Distinct published reports

Individual concerns
15

A report can raise multiple concerns

Date range
2013–2026

First to latest report issue date

Stated actions
13

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.

Care Quality Commission3
Department of Health and Social Care2
Cardiff & Vale University LHB1
Cwm Taf Morgannwg University Local Health Board1
Doncaster and Bassetlaw Teaching Hospitals NHS Foundation Trust1
East Cheshire NHS Trust1
General Medical Council1
Liverpool University Hospitals NHS Foundation Trust1
NHS Cheshire and Merseyside Integrated Care Board1
NHS England1
North Cumbria Integrated Care NHS Foundation Trust1
Nursing and Midwifery Council1
Public Health England1
Royal Cornwall Hospital1
Royal Cornwall Hospitals NHS 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. Nottinghamshire

    AI-generated summary

    Kathleen McGeary · 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

    Kathleen McGeary died on 6 March 2018 from a head injury sustained in a fall at Tuxford Manor Care Home after her discharge from hospital. Concerns included inadequate assessment and treatment before discharge, unclear responsibility for discharge decisions, inadequate discharge documentation and communication, and her leaving hospital without prescribed antibiotics.

    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 prescribed antibiotics at discharge

    Wider context from the report

    “4. Mrs McGeary left hospital by hospital arranged transport without the antibiotics she had been prescribed for a suspected UTI. No explanation was given for this failing. ”

    Source location

    Kathleen McGeary · Prevention of Future Deaths report
    Page 1 · concerns

    Open source report

  2. Liverpool and the Wirral

    AI-generated summary

    Tom Cribley · 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

    Tom Cribley attended Aintree hospital on 18 February 2017 with vomiting, diarrhoea and a rash, and was later diagnosed with meningococcal sepsis. The report identifies concerns including failures to document and escalate the rash and deteriorating observations, inadequate handovers and reassessment, delayed recognition of abnormal blood results, and delayed antibiotic treatment. Tom did not recover and died on 20 February 2017.

    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 administering antibiotic therapy during clinical deterioration

    Wider context from the report

    “A RCA revealed a number of failings by the Trust including in respect of some matters that had been previously raised by the Care Quality Commission and required action. The failings identified by the Trust and those found by the Jury included; inter alia failing to document important clinical findings for example the failure to document the rash that Tom presented with when he arrived at AED which was not recorded at triage. The failure to escalate the NEWS (National Modified Early Warning Score) in a timely manner to medical staff and to repeat observations hourly in accordance with the NEWS policy. The failure to complete a full “PIT STOP” review, the failure to review the initial diagnosis of gastroenteritis when Tom’s condition continued to deteriorate, the failure of clinical staff to handover clinical concerns to each other and to medical staff including face to face handovers, the failure to escalate monitoring and management appropriately in particular following receipt of the first set of grossly abnormal blood results, the failure to administer antibiotic therapy until 23.00 hrs this even when Tom’s condition continued to deteriorate and the rash that he presented with began to spread and appeared to change in both colour, size and location during which time Tom was becoming increasingly unwell, he had been a fit and well 28 year old prior to his attendance in AED. There was also an admitted failure to escalate appropriately and to convey the magnitude and severity of Tom’s condition and deterioration to the Critical Care Team, who described him as being “in extremis” when the Critical care doctor arrived shortly after 23.00hrs. The care and treatment from 2300hrs onwards on 18/02/2017 was regarded as wholly appropriate but sadly Tom did not recover and he died on 20/02/2017. Aintree University Hospital have put an action plan in place to address the failings identified within the RCA however such is the concern of the Coroner pertaining to the training needs of clinical staff (doctors and nurses) in respect of the identification and treatment of sepsis and meningococcal sepsis in particular that the Coroner requires a report and action plan which clearly identifies a systematic, consistent and comprehensive ongoing training programme which identifies not only the training plan that will be implemented across the Trust but also how the training plans implementation will be monitored in respect of consistency of approach, compliance and effectiveness. The Trust has produced a number of action plans on previous occasions following Care Quality Commission Reviews, however, some of the failings identified in the issues touching the death of Tom Cribley have also been identified on previous occasions. Robust monitoring and ownership of the training programme, implementation and review is required from the very top of the organisation up to and including the Trust Board. This leadership and ownership from the top will be fundamental to the achievement of meaningful and sustained improvements in the provision of education and training in this most challenging clinical area. ”

    Source location

    Tom Cribley · Prevention of Future Deaths report
    Page 3 · concerns

    Open source report

  3. Black Country

    AI-generated summary

    Mrs Natalie Billingham · 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 Natalie Billingham was admitted to hospital with worsening foot pain, later developed necrotising fasciitis, underwent emergency surgery including a through-knee amputation, and died on the evening of 2 March 2018. The report identified concerns about inadequate communication and delays in reviewing abnormal blood results, recognising sepsis, and administering antibiotics.

    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 administer antibiotics at an earlier stage

    Wider context from the report

    “1. Evidence emerged during the inquest that there was inadequate communication and delays in assessing the blood results when available. There were also missed opportunities for administering antibiotics at an earlier stage and recognising the development of sepsis. ”

    Source location

    Mrs Natalie Billingham · Prevention of Future Deaths report
    Page 3 · concerns

    Open source report

  4. Brighton and Hove

    AI-generated summary

    MARTIN ARNOLD HILL · 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

    MARTIN ARNOLD HILL arrived at A & E on 28 March 2014 after approximately three days of confusion, abdominal pain and vomiting, with raised inflammatory markers. The concerns included delayed antibiotics, failures to refer him to the Critical Care Outreach Team when his NEWS was elevated, inadequate withdrawal treatment, failures in managing constipation, poor handover and communication, and serious omissions in the Medical Administration Record.

    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 commencing antibiotics for patients requiring antimicrobial treatment

    Wider context from the report

    “(1) Although this man arrived in A & E on the 28th March 2014 at approximately 12:30, having been suffering confusion, abdominal pain and vomiting for some three days with raised white cell count and markedly raised C-Reactive Protein. He was not commenced on antibiotics until over 48 hours later at 14:00 hours on the 30th March, 2014. At Inquest I was told that he should have been commenced on Pragmatic antibiotics shortly after his arrival and assessment by a Doctor in A & E. ”

    Source location

    MARTIN ARNOLD HILL · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

  5. Manchester City

    AI-generated summary

    Anthony Bernard McCormick · 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

    Anthony Bernard McCormick was admitted to hospital with gastrointestinal symptoms, vomiting, lethargy, fever and rigors, and was later found to have liver abscesses and gallstones. He underwent surgery but developed pneumonia and sepsis and died on 31 May 2011; the post-mortem found extensive empyema and sepsis. Concerns included delays in urgent admission, diagnosis, specialist referral and surgery, failures in communication and clinical review, and gaps in appropriate antibiotic treatment.

    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 continuous appropriate antibiotic therapy

    Wider context from the report

    “5. Throughout the course of his clinical care at Macclesfield Hospital there was a failure to ensure that he consistently received appropriate antibiotic therapy without avoidable gaps in treatment. 6. The deceased had not been referred in a timely and appropriate manner for the Cholecystectomy following the HPB MDT on 9 March 2011 and was not provided with appropriate antibiotic cover to ensure resolution of his liver abscesses ”

    Source location

    Anthony Bernard McCormick · Prevention of Future Deaths report
    Page 3 · concerns

    Open source report
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Data last updated 7 September 2026