Recurring concern

Unreliable management of post-discharge infection risks

First to latest report 3 Jan 2014 — 19 Jul 2023

Reports that mention this concern: 2
Times this concern has been raised: 5
Stated actions linked to this concern: 2

What this concern includes

Includes failures of controls specifically dedicated to managing possible or emerging infection after discharge from secondary care, including condition-specific discharge planning, recording and escalation of infection concerns, review of relevant test results, and timely clinical assessment or treatment.

What is not included

Excludes general discharge-planning, discharge-communication or follow-up failures where no post-discharge infection risk is identified.
Excludes infection-control measures intended to prevent infection during treatment or procedures, rather than management of infection risk after discharge.
Excludes generic clinical record-keeping, communication or escalation deficiencies unless they directly concern a post-discharge infection risk.
Excludes treatment failures after a post-discharge infection concern has been reliably identified and appropriately escalated, where the infection-risk management process itself was not deficient.

Trends

Reports over time

Reports mentioning this concern, over time

Reports about this concern issued each year.

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

Most frequent recipients

Reports about this concern sent to each recipient.

Leeds Teaching Hospitals NHS Trust1

NHS North of England Commissioning Support Unit1

South Tyneside and Sunderland NHS Foundation Trust1

the Newcastle Upon Tyne Hospitals NHS Foundation Trust1

Trinity Medical Centre, South Shields1

York Hospital1

Reports and published responses 2 reports

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

19 Jul2023
North Yorkshire and York
Concerns raised2
1. Failure to record post-discharge infection concerns
2. Failure to escalate suspected infection concerns to the treating team
This report raised 8 other concerns. They are not shown here because they do not form part of this recurring concern.
Linked responses

Leeds Teaching Hospitals NHS Trust
York and Scarborough Teaching Hospitals NHS Foundation Trust
Stated actions 2
1. York and Scarborough Teaching Hospitals NHS Foundation Trust
  Update and disseminate clinical record-keeping guidance to clinical staff.
2. Leeds Teaching Hospitals NHS Trust
  Require staff to record recent post-discharge contacts, advice, investigations and clinicians in PPM+, and forward review requests to outpatient teams.
AI-generated summary

Carole MCQUINN · 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

Carole MCQUINN underwent pancreatic surgery in February 2022 and subsequently experienced pancreatic leakage, abdominal collections and prolonged hospital treatment. After discharge without a discharge note, medication or follow-up appointment, concerns about infection were not adequately recorded or escalated, and a positive swab result was not reviewed until several days later. She was later admitted with suspected intra-abdominal sepsis and was found unresponsive in hospital; the inquest concluded that she died from a pulmonary embolism likely related to post-operative infection, inflammation and immobility.

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 record post-discharge infection concerns
Wider context from the report
“2. Trust staff interacting with the deceased and her daughter regarding infection concerns arising in the post-discharge period between 21/4/22 and 3/5/22 made no records of the same. Nursing staff were shown photographs of the deceased's drain site, and issued stoma bags and a swab to her daughter for suspected infection, but did not flag this development to the treating team or make arrangements for the results of the swabs to be reviewed. No clinical observations of the deceased were recorded when she attended the hospital on 3/5/22. The swab result did not come to anyone's attention or get reviewed until the deceased's daughter flagged the issue to staff on 3/5/22. These omissions led to missed opportunities for earlier assessment and treatment of the deceased. ”
Source location
Carole MCQUINN · 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 escalate suspected infection concerns to the treating team
Wider context from the report
“2. Trust staff interacting with the deceased and her daughter regarding infection concerns arising in the post-discharge period between 21/4/22 and 3/5/22 made no records of the same. Nursing staff were shown photographs of the deceased's drain site, and issued stoma bags and a swab to her daughter for suspected infection, but did not flag this development to the treating team or make arrangements for the results of the swabs to be reviewed. No clinical observations of the deceased were recorded when she attended the hospital on 3/5/22. The swab result did not come to anyone's attention or get reviewed until the deceased's daughter flagged the issue to staff on 3/5/22. These omissions led to missed opportunities for earlier assessment and treatment of the deceased. ”
Source location
Carole MCQUINN · 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
Update and disseminate clinical record-keeping guidance to clinical staff.

Verbatim wording from the response
“On review of this matter it became apparent that the Trust’s clinical record-keeping guidance was out of date. This was already on the work plan to be updated and will now be expedited. Once the guidance is finalised it will be shared with all clinical staff.”

Source location
Response from York and Scarborough Teaching Hospitals NHS Foundation Trust
Page 1 · response
Published 21 July 2023
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
Require staff to record recent post-discharge contacts, advice, investigations and clinicians in PPM+, and forward review requests to outpatient teams.

Verbatim wording from the response
“The problems that arose in this case have been discussed at ward meetings. Staff have been instructed that all contact with recently discharged patients and their relatives must be recorded on the Trust’s electronic case record system PPM+ for the first 7 days after discharge at least. Notes made must include details of advice given, any investigations undertaken or arranged and the clinicians involved. Staff have also been informed that requests for advice or review should be forwarded to the outpatient team to facilitate early face to face assessment, coordination of any additional investigations, formal review of results and appropriate communication with the patient and family members afterwards.”

Source location
Response from Leeds Teaching Hospitals NHS Foundation Trust
Page 3 · response
Published 21 July 2023
Open published response
3 Jan2014
Gateshead and South Tyneside
Concerns raised3
1. Failure to communicate relevant postoperative risks and complications to community carers
2. Failure of surgical teams to maintain ongoing oversight after discharge
3. Lack of a discharge plan for possible pelvic infection
This report raised 2 other concerns. They are not shown here because they do not form part of this recurring concern.
No linked response statements
No respondent-stated action or position is linked to these concerns in the published data.
AI-generated summary

Keith Fleming · 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

Keith Fleming underwent elective reversal of an ileostomy in January 2013 and was discharged home on 14 January. He developed an unrecognised internal infection, was admitted as an emergency on 6 February, and died on 10 February 2013 despite urgent treatment. The substantive concerns included the absence of recorded temperature and blood pressure readings, insufficient monitoring and communication between surgical and community services, and inadequate care planning and record keeping after discharge.

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 communicate relevant postoperative risks and complications to community carers
Wider context from the report
“The General Practitioner and consequently the nursing staff were not aware of that the anastomosis of the bowel carried out during the original operation ( 2007) had dehised. Nor were they aware of an internal area of abscess adjacent to the repaired stoma site , only discovered on post mortem and together leading to a catastrophic infection within the deceased particularly and significantly in the area of his left buttock. The reality was the infection within the otherwise pelvic area had tracked through the pelvis into the area of the left buttock. It was the presence of the swelling of this area of the buttock which was to alert the deceased’ wife several days after his discharge home to the growing crisis and resulted in her summoning her husband’s GP Dr.████████. The Doctor immediately recognized the symptoms, arranged for the deceased’ emergency admission to the South Tyneside District Hospital. ”
Source location
Keith Fleming · 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 of surgical teams to maintain ongoing oversight after discharge
Wider context from the report
“Whilst it has to be acknowledged in early correspondence to his GP from Professor████████ the surgeon in charge of the patient at the Freeman Hospital the possibility of pelvic infection was mooted as a risk factor in the proposed reversal -- no plans specifically provided on discharge for this possible contingency or appears. On discharge the care of the deceased was to be managed within the Community and the deceased was to be seen by the surgical team as “a follow up” some time in the future. ”
Source location
Keith Fleming · 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
Lack of a discharge plan for possible pelvic infection
Wider context from the report
“Whilst it has to be acknowledged in early correspondence to his GP from Professor████████ the surgeon in charge of the patient at the Freeman Hospital the possibility of pelvic infection was mooted as a risk factor in the proposed reversal -- no plans specifically provided on discharge for this possible contingency or appears. On discharge the care of the deceased was to be managed within the Community and the deceased was to be seen by the surgical team as “a follow up” some time in the future. ”
Source location
Keith Fleming · Prevention of Future Deaths report
Page 2 · concerns
Open source report