Unreliable investigation of serious infection causes
First to latest report 2 Oct 2014 — 10 Mar 2026
Reports that mention this concern
6
Times this concern has been raised
6
Stated actions linked to this concern
13
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.
What is 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.
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
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
Reports and published responses 6 reports
See individual reports that have raised this concern, and the actions taken in response
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.
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.
Linked responses
Barking, Havering and Redbridge University Hospitals NHS Trust
Department of Health and Social Care
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.2
Department of Health and Social Care
BHRUT is responsible for responding to the broader concerns raised about Mrs Creegan’s care and the application of PSIRF.
Redirects responsibilityThe respondent said that another organisation was responsible for deciding or taking action.
Barking, Havering and Redbridge University Hospitals NHS Trust
Further invasive or extensive investigation was not considered clinically appropriate because it was unlikely to alter management or improve outcomes.
No 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.
Linked responses
UCLH Trust
UK Health Security Agency
Stated actions An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.1
UK Health Security Agency
Share UKHSA regional team contact details with immediate family so they can ask questions or provide further information.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1
UCLH Trust
Community outbreak investigations do not fall directly within the Trust’s infection prevention and control teams’ scope of practice.
Outside 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.
Linked responses
Darwin Medical Practice
The Trust
University Hospitals Birmingham NHS Foundation Trust
Stated actions An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.12
Darwin Medical Practice
Review the case and discuss its learning at a clinical governance meeting.
Darwin Medical Practice
Consider infection arising from pacemaker leads as a possible cause in future similar presentations.
University Hospitals Birmingham NHS Foundation Trust
Review endocarditis guidelines to confirm coverage of device-related infection and endocarditis.
University Hospitals Birmingham NHS Foundation Trust
Deliver grand-round education to acute physicians on recognising pacemaker-related endocarditis.
University Hospitals Birmingham NHS Foundation Trust
Circulate a Lesson of the Month email to staff on pacemaker-related endocarditis signs and symptoms.
University Hospitals Birmingham NHS Foundation Trust
Update pacemaker patient leaflets with instructions to seek medical attention and alert clinicians when fever exceeds 38°C.
The Trust
Complete governance approval of the cardiac device infection guideline.
The Trust
Link the cardiac device infection guideline to existing pyrexia-of-unknown-origin guidance.
The Trust
Disseminate the approved guideline through the intranet and divisional clinical leadership meetings.
The Trust
Share inquest learning with the Department of Medicine to raise staff awareness.
The Trust
Review organisational guidance for identifying and diagnosing cardiac rhythm device infections.
The Trust
Highlight the learning and related guidelines in the monthly Patient Safety Brief newsletter.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.4
Darwin Medical Practice
The infection could not have been identified earlier within primary care because symptoms were nonspecific and appropriate steps were taken.
Disputes the concernThe respondent disagreed with part of the concern or the basis for it.
Darwin Medical Practice
Responsibility for the final diagnosis lay probably more within secondary care than primary care.
Redirects responsibilityThe respondent said that another organisation was responsible for deciding or taking action.
University Hospitals Birmingham NHS Foundation Trust
The existing endocarditis guidelines are considered comprehensive, including device-related infection and endocarditis, and require no amendment.
Existing arrangements considered sufficientThe respondent said that existing arrangements were sufficient, so no further action was needed.
University Hospitals Birmingham NHS Foundation Trust
Existing patient leaflets are considered sufficient regarding infection symptoms and contact details, although additional fever instructions will be added.
Existing 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.
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.
No linked response statements
No respondent-stated action or position is linked to these concerns in the published data.
Actions and positions describe what organisations say in published responses. Implementation is not independently verified.
Actions and positions describe what organisations say in published responses. Implementation is not independently verified.