First reported 2 Oct 2014•Latest report 10 Mar 2026
Definition
What this concern includes
Includes failures of clinical or governance processes specifically intended to investigate and establish the cause, source, origin or treatment relationship of a serious infection, including investigation of whether an infection pre-existed treatment or arose from treatment and investigation of the source of a progressing infection.
Not included
Excludes routine infection testing, monitoring or treatment failures where the asserted concern is not investigation of the infection's cause or source.
Excludes generic incident, death or root-cause investigations unless the investigation specifically concerns establishing the cause or source of a serious infection.
Excludes failures to recognise, escalate or treat infection where the causal-investigation process is not itself deficient.
Excludes the quality of clinical care or the occurrence of an infection where no failure to investigate its cause or source is identified.
Reports
6
Distinct published reports
Individual concerns
6
A report can raise multiple concerns
Date range
2014–2026
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.
Barking, Havering and Redbridge University Hospitals NHS Trust2
Department of Health and Social Care2
Barts Health NHS Trust1
Care Quality Commission1
Darwin Medical Practice1
Good Hope Hospital1
NHS Bath and North East Somerset, Swindon and Wiltshire Integrated Care Board1
Queen's Hospital, Burton1
Royal United Hospitals Bath NHS Foundation Trust1
UK Health Security Agency1
University College London Hospitals NHS Foundation Trust1
University Hospitals Birmingham NHS Foundation Trust1
University Hospitals of Derby and Burton NHS Foundation Trust1
NHS trust6
Ministerial department2
Executive agency1
Health and social care service regulator1
Healthcare site1
Integrated care board1
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.
East London
Concerns raised1
Failure to establish the aetiology and timing of a fatal 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 concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements
No respondent-stated action or position is linked to these concerns in the published data.
East London
Concerns raised1
Failure to investigate the source of a progressing infection after pneumonia resolves
This report raised 4 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each 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.2
Position
BHRUT is responsible for responding to the broader concerns raised about Mrs Creegan’s care and the application of PSIRF.
Stated by Department of Health and Social CareRedirects responsibilityThe respondent said that another organisation was responsible for deciding or taking action.
Position
Further invasive or extensive investigation was not considered clinically appropriate because it was unlikely to alter management or improve outcomes.
Stated by Barking, Havering and Redbridge University Hospitals NHS TrustNo action considered necessaryThe respondent said that no further action was needed.
Inner North London
Concerns raised1
Failure to obtain relevant exposure information from household contacts during E coli source investigation
This report raised 4 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each 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
Action
Share UKHSA regional team contact details with immediate family so they can ask questions or provide further information.
Stated by UK Health Security AgencyStated plannedThe respondent said that this action was planned when they made their response on 17 September 2024.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1
Position
Community outbreak investigations do not fall directly within the Trust’s infection prevention and control teams’ scope of practice.
Stated by UCLH TrustOutside remitThe respondent said that this matter was outside its role or authority.
Stoke-on-Trent and North Staffordshire
Concerns raised1
Failure to consider pacemaker box change as a potential source of 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 concerns
Each 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.12
Action
Review the case and discuss its learning at a clinical governance meeting.
Stated by Darwin Medical PracticeStated completedThe respondent said that this action was complete when they made their response on 9 September 2019.
Action
Consider infection arising from pacemaker leads as a possible cause in future similar presentations.
Stated by Darwin Medical PracticeStated plannedThe respondent said that this action was planned when they made their response on 9 September 2019.
Action
Review endocarditis guidelines to confirm coverage of device-related infection and endocarditis.
Stated by University Hospitals Birmingham NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 9 September 2019.
Action
Deliver grand-round education to acute physicians on recognising pacemaker-related endocarditis.
Stated by University Hospitals Birmingham NHS Foundation TrustStated in progressThe respondent said that this action was in progress when they made their response on 9 September 2019.
Action
Circulate a Lesson of the Month email to staff on pacemaker-related endocarditis signs and symptoms.
Stated by University Hospitals Birmingham NHS Foundation TrustStated plannedThe respondent said that this action was planned when they made their response on 9 September 2019.
Action
Update pacemaker patient leaflets with instructions to seek medical attention and alert clinicians when fever exceeds 38°C.
Stated by University Hospitals Birmingham NHS Foundation TrustStated plannedThe respondent said that this action was planned when they made their response on 9 September 2019.
Action
Complete governance approval of the cardiac device infection guideline.
Stated by The TrustStated in progressThe respondent said that this action was in progress when they made their response on 9 September 2019.
Action
Link the cardiac device infection guideline to existing pyrexia-of-unknown-origin guidance.
Stated by The TrustStated plannedThe respondent said that this action was planned when they made their response on 9 September 2019.
Action
Disseminate the approved guideline through the intranet and divisional clinical leadership meetings.
Stated by The TrustStated plannedThe respondent said that this action was planned when they made their response on 9 September 2019.
Action
Share inquest learning with the Department of Medicine to raise staff awareness.
Stated by The TrustStated completedThe respondent said that this action was complete when they made their response on 9 September 2019.
Action
Review organisational guidance for identifying and diagnosing cardiac rhythm device infections.
Stated by The TrustStated completedThe respondent said that this action was complete when they made their response on 9 September 2019.
Action
Highlight the learning and related guidelines in the monthly Patient Safety Brief newsletter.
Stated by The TrustStated plannedThe respondent said that this action was planned when they made their response on 9 September 2019.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.4
Position
The infection could not have been identified earlier within primary care because symptoms were nonspecific and appropriate steps were taken.
Stated by Darwin Medical PracticeDisputes the concernThe respondent disagreed with part of the concern or the basis for it.
Position
Responsibility for the final diagnosis lay probably more within secondary care than primary care.
Stated by Darwin Medical PracticeRedirects responsibilityThe respondent said that another organisation was responsible for deciding or taking action.
Position
The existing endocarditis guidelines are considered comprehensive, including device-related infection and endocarditis, and require no amendment.
Stated by University Hospitals Birmingham NHS Foundation TrustExisting arrangements considered sufficientThe respondent said that existing arrangements were sufficient, so no further action was needed.
Position
Existing patient leaflets are considered sufficient regarding infection symptoms and contact details, although additional fever instructions will be added.
Stated by University Hospitals Birmingham NHS Foundation TrustExisting arrangements considered sufficientThe respondent said that existing arrangements were sufficient, so no further action was needed.
Avon
Concerns raised1
Failure to correctly interpret microbiological water-sample results and testing limitations
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 concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements
No respondent-stated action or position is linked to these concerns in the published data.
London (East)
Concerns raised1
Failure to identify the source of infection during clinical deterioration
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 concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements
No respondent-stated action or position is linked to these concerns in the published data.
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Includes failures of clinical or governance processes specifically intended to investigate and establish the cause, source, origin or treatment relationship of a serious infection, including investigation of whether an infection pre-existed treatment or arose from treatment and investigation of the source of a progressing infection.
