Recurring concern

Unreliable prevention and management of infective endocarditis

First to latest report 11 Mar 2019 — 10 Mar 2026

Reports that mention this concern
4
Times this concern has been raised
5
Stated actions linked to this concern
6

What this concern includes

Includes failures of controls specifically dedicated to preventing, recognising, investigating or managing infective endocarditis, including dental-procedure implementation guidance for at-risk patients, clinician competence and awareness, relevant blood cultures or other diagnostic testing, referral and treatment decisions.

What is not included
  • Excludes general dental hygiene or dental-service provision where infective endocarditis prevention or management is not identified.
  • Excludes generic clinical guidance, training or diagnostic-testing deficiencies without a material infective-endocarditis connection.
  • Excludes general anticoagulation, antibiotic or infection-management concerns where infective endocarditis is not the supported hazard.
  • Excludes failures occurring after infective endocarditis has been reliably diagnosed and managed when the remaining issue is unrelated downstream care.

Reports and published responses 4 reports

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

  1. East London

    AI-generated summary

    Sheila Creagan · 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

    Sheila Creagan, an 81-year-old woman with heart failure, underwent emergency abdominal surgery in February 2025 and was later admitted with breathing difficulties, anaemia and a suspected gastrointestinal bleed. She died in hospital on 17 March 2025; the inquest determined that untreated and undiagnosed infective endocarditis caused her death. Concerns included the failure to investigate the source of her worsening infection, the missed diagnosis of infective endocarditis, inadequate monitoring of her heart failure, and the decision not to conduct a Patient Safety Framework investigation.

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    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 diagnose infective endocarditis

    Wider context from the report

    “1. BHRUT chose not to investigate this case as part of NHS England’s Patient Safety Framework. Mrs Creagan’s death ought to have been subject to such an investigation. Decisions were reached at two clinical governance meetings that meaningful learning could not flow from a governance investigation into the circumstances of Mrs Creagan’s care. Such decisions appear to be incongruous with; a. The inaccurate cause of death initially offered by the Trust, b. The failure to investigate the seat of Mrs Creagan’s burgeoning infection after her pneumonia resolved. c. The missed diagnosis of infective endocarditis, d. The failure to monitor the development of Mrs Creagan’s heart failure during her inpatient treatment. ”

    Source location

    Sheila Creagan · Prevention of Future Deaths report
    Page 3 · concerns

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    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

    Operate the Coroner’s Case Review Meeting as a formal governance mechanism for multidisciplinary oversight of inquest and coronial cases.

    Verbatim wording from the response

    “To have good governance process to support these decisions, HM Coroner will be aware that the Trust has now established a Coroner’s Case Review Meeting (CCRM) as part of its formal coronial governance arrangements.”

    Source location

    Response from Barking, Havering and Redbridge University Hospitals NHS Trust
    Page 1 · response
    Published 18 March 2026

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    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 multidisciplinary clinical review of relevant coronial cases, including cases involving concerns about diagnosis, deterioration, monitoring, treatment or missed opportunities.

    Verbatim wording from the response

    “The Trust has reflected carefully on the concern expressed in the Report that meaningful learning should have flowed from the circumstances of Mrs Creegan’s care. We accept the need to demonstrate clearly, in coronial cases, that learning is being actively pursued and is not dependent on PSIRF alone. Our revised approach is that coronial cases of this nature will be considered through the CCRM and, where relevant, alongside other existing review methodologies so that there is explicit multidisciplinary scrutiny, clear senior clinical oversight, and a documented record of the Trust’s appraisal of the care and the resulting actions.”

    Source location

    Response from Barking, Havering and Redbridge University Hospitals NHS Trust
    Page 2 · response
    Published 18 March 2026

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    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

    Use multiple review routes, including MDT, mortality, complaints, clinician reflection and CCRM reviews, rather than relying solely on PSIRF.

    Verbatim wording from the response

    “The Trust agrees that learning should not be constrained by whether a case meets a particular PSIRF learning response threshold. In these cases, a number of review methods have been, and continue to be, used to examine the care provided and identify learning. These include:”

    Source location

    Response from Barking, Havering and Redbridge University Hospitals NHS Trust
    Page 2 · response
    Published 18 March 2026

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    Source evidence

    How this respondent position was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    BHRUT is responsible for responding to the broader concerns raised about Mrs Creegan’s care and the application of PSIRF.

    Verbatim wording from the response

    “In preparing this response, my officials have made enquiries with NHS England and the Care Quality Commission (CQC) to ensure we adequately address your concerns on PSIRF. I note you have also copied your report to Barking, Havering, and Redbridge University Hospitals NHS Trust (BHRUT) who will respond to the broader concerns you have raised.”

    Source location

    Response from Department of Health and Social Care
    Page 1 · response
    Published 18 March 2026

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    Source evidence

    How this respondent position was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    There were no clinical indicators during life that would reasonably have prompted investigation or diagnosis of bacterial endocarditis.

    Verbatim wording from the response

    “The postmortem diagnosis of bacterial endocarditis was unexpected. During life, Mrs. Creegan did not display classical features that would have prompted suspicion, such as persistent bacteraemia, new cardiac murmurs, embolic phenomena, or a deteriorating cardiac picture unexplained by existing conditions.”

    Source location

    Response from Barking, Havering and Redbridge University Hospitals NHS Trust
    Page 4 · response
    Published 18 March 2026

    Open published response

  2. Gwent

    AI-generated summary

    Alan Bevis TOMLINSON · 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

    Alan Bevis TOMLINSON attended hospital on 16 April 2024 with illness, significant weight loss, anaemia and swelling around his pacemaker site, but was advised to return home because no cardiac bed was available. He died at home on 18 April 2024 from the effects of untreated infective endocarditis, likely associated with a longstanding infection at the pacemaker implant site. Concerns included missed referral to cardiology despite increasing pacemaker thresholds and visible illness, and failures to identify infective endocarditis, gather and document clinical information, and communicate findings effectively.

    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

    Limited physiologist knowledge of infective endocarditis

    Wider context from the report

    “Evidence from the Chief Physiologist identified wider concerns within the service, including: 1. Lack of guidance on when pacemaker data should trigger cardiology review; 2. Limited physiologist knowledge of infective endocarditis; 3. Inconsistent gathering of clinical information and implant site checks during clinic visits; 4. How clinical findings were documented and communicated, particularly to the Cardiology team. ”

    Source location

    Alan Bevis TOMLINSON · 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

    Deliver physiologist training on infective endocarditis, unwell-patient red flags, and cardiology escalation.

    Verbatim wording from the response

    “Training and Education for Physiologists”

    Source location

    Response from Cardiff and Vale University Health Board
    Page 2 · response
    Published 10 March 2026

    Open published response

  3. Derby and Derbyshire

    AI-generated summary

    Michael BRIGGS · 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

    Michael Briggs developed infective endocarditis after three dental extractions and died at Royal Derby Hospital on 11 January 2023. The principal concerns were limited guidance for dentists in England and Wales about managing patients at increased risk of infective endocarditis, and conflicting guidance on antibiotic prophylaxis.

    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

    Lack of implementation advice for dentists in England and Wales managing patients at increased risk of infective endocarditis

    Wider context from the report

    “• The NICE guideline CG64 “Prophylaxis against infective endocarditis” states that antibiotic prophylaxis against infective endocarditis is not recommended routinely for people undergoing dental procedures. The guideline does not provide any implementation advice for dentists on how they should manage patients who are at an increased risk. • The Scottish Dental Clinical Effectiveness Programme (SDCEP) produced implementation advice in August 2018 entitled “Antibiotic Prophylaxis Against Infective Endocarditis”. The document contains a “NICE Statement of Endorsement” that the advice supports the implementation of recommendations in CG64. There is no reciprocal endorsement or mention of the SDCEP advice in CG64 and there does not appear to be any such implementation advice applicable to dentists in England and Wales. ”

    Source location

    Michael BRIGGS · 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

    Conflicting guidance on antibiotic prophylaxis for people at high risk of infective endocarditis

    Wider context from the report

    “• In 2023 the European Society of Cardiology (ESC) produced Clinical Practice Guidelines for the management of endocarditis which recommends antibiotic prophylaxis for high risk individuals. The court heard evidence that cardiologists in England and Wales are regularly following this guidance which conflicts with the 2016 NICE guideline. ”

    Source location

    Michael BRIGGS · 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

    Review evidence on antibiotic prophylaxis against infective endocarditis and determine whether new information supports updating NICE guidance.

    Verbatim wording from the response

    “We have committed to review the current evidence relating to prophylaxis against infective endocarditis this financial year and will determine whether any new information, studies or research would support the case for a further update of existing NICE guidance.”

    Source location

    Response from National Institution for Health and Care Excellence
    Page 2 · response
    Published 29 April 2024

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    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

    Review evidence on antibiotic prophylaxis against infective endocarditis, including dental extraction, and assess whether prophylaxis was effective.

    Verbatim wording from the response

    “In the 2015 review of CG64, the guideline committee agreed that current evidence was insufficient to support the hypothesis that interventional procedures, including dental extraction, lead to the development of infective endocarditis in people with pre-existing cardiac conditions. Furthermore, the committee concluded that there is insufficient evidence to recommend prophylactic use of antibiotics in those at risk of infective endocarditis undergoing interventional procedures, including dental extraction. From the evidence examined, the committee were unable to establish whether or not prophylaxis was effective.”

    Source location

    Response from National Institution for Health and Care Excellence
    Page 1 · response
    Published 29 April 2024

    Open published response

  4. Manchester City

    AI-generated summary

    Margaret Bernadette WILSON · 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

    Margaret Bernadette Wilson was admitted with swelling, pain and bruising, and was provisionally diagnosed with cellulitis and treated with antibiotics without prior blood tests. She later developed chest pain, was diagnosed with endocarditis, did not respond to treatment and died. The report identified concern that the absence of a blood test and the prescribing of antibiotics masked the endocarditis, and stated that earlier diagnosis and treatment would more likely than not have resulted in a different outcome.

    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 perform a guideline-compliant blood test for Endocarditis

    Wider context from the report

    “1. A blood test should have been done, in compliance with national guidelines, which would have confirmed Endocarditis. The absence of such test and the prescribing of antibiotics masked the disease. 2. Earlier diagnosis and treatment would more likely than not have resulted in a different outcome. In addition it was later recognised that the finger symptoms were most likely due to Endocarditis. ”

    Source location

    Margaret Bernadette WILSON · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

Actions and positions describe what organisations say in published responses. Implementation is not independently verified.

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Data last updated 7 September 2026