Recurring concern

Failure to control infection risks during care

First to latest report 22 Sep 2014 — 28 Dec 2025

Reports that mention this concern
7
Times this concern has been raised
7
Stated actions linked to this concern
3

What this concern includes

Includes failures of infection-prevention controls directly connected to care delivery, including cleanliness of care environments and equipment, aseptic or hygienic clinical procedures, required environmental cleaning, and hand hygiene or comparable precautions for people providing or receiving care.

What is not included
  • Excludes diagnosis, treatment or monitoring of an established infection where infection-prevention controls are not deficient.
  • Excludes generic staffing, training, documentation or governance failures unless they directly impair an infection-prevention control.
  • Excludes general environmental cleanliness concerns with no identified care-related infection risk.
  • Excludes infection risks in food preparation, public premises or industrial settings unless the assertion directly concerns infection prevention during care.

Reports and published responses 7 reports

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

  1. West London

    AI-generated summary

    Mohamed Abdisamad · 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

    Mohamed Abdisamad underwent a non-therapeutic male circumcision on 12 February 2023 and developed symptoms of illness three to four days later. He suffered a cardiorespiratory arrest while being taken to hospital and was declared dead on 19 February 2023; the inquest recorded invasive Streptococcus pyogenes infection following male circumcision as the medical cause of death. The report raised concerns about the lack of training, accreditation, record keeping, consent, infection-control requirements and aftercare requirements for individuals conducting such procedures.

    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 infection control requirements for NTMC

    Wider context from the report

    “5. There is no requirement for any infection control measures for a Non-Therapeutic Male Circumcisions (NTMC). ”

    Source location

    Mohamed Abdisamad · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

    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

    Responsibility for the reported issues rests with DHSC, which has provided the comprehensive government response; MHCLG has nothing further to add.

    Verbatim wording from the response

    “MHCLG is responsible for the overall stewardship of the local government sector, but we are not responsible for all the services that councils deliver. Councils deliver a very wide range of services to residents, within a national legislative framework. Decisions around management are often taken locally, but the lead Government department for any particular issue delivered by a local authority is responsible for working with councils to ensure effective delivery.”

    Source location

    Response from MHCLG
    Page 1 · response
    Published 29 December 2025

    Open published response

  2. South Yorkshire (Eastern)

    AI-generated summary

    Walter Colin HORTON · 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

    Walter Colin HORTON, an 88-year-old male, died in a nursing home on 10 January 2025. The recorded causes included sepsis and an advanced sacral pressure sore, with ischaemic heart disease also noted. Concerns included poor record keeping and failures to understand or follow aseptic techniques and cleanliness when managing wounds, increasing the risk of infection.

    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 use aseptic techniques and maintain cleanliness during wound management

    Wider context from the report

    “(1) Poor record keeping in regard to key areas of care namely falls and wound management and handover information on discharge (2) A failure to understand or to follow use of aseptic techniques and cleanliness when managing wounds thus increasing the risk of infection. ”

    Source location

    Walter Colin HORTON · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

    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 was no evidence of an aseptic technique breach during wound care.

    Verbatim wording from the response

    “• A detailed review found no evidence of breach in aseptic technique during wound care.”

    Source location

    Response from Doncaster and Bassetlaw Teaching Hospitals NHS FT
    Page 2 · response
    Published 19 September 2025

    Open published response

    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

    The Trust disputes that wound care involved a breach of aseptic technique, stating that review found no evidence of one.

    Verbatim wording from the response

    “4. Aseptic Technique and Wound Cleanliness”

    Source location

    Response from Doncaster & Bassetlaw NHS Foundation Trust
    Page 2 · response
    Published 19 September 2025

    Open published response

  3. County Durham and Darlington

    AI-generated summary

    Patricia Heather Lines · 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

    Patricia Heather Lines became unwell after receiving an intramuscular Vitamin B12 injection into her right shoulder and died in hospital on 23 October 2023 after developing an invasive Group A Streptococcus infection. The report states that the likely source of the infection was the injection, with bacteria introduced from the skin into deeper shoulder tissues. A principal concern was that the administering nurse did not clean the skin, in accordance with existing training and national guidance, despite evidence that alcohol cleaning reduces bacterial counts and that the supporting literature was over 20 years old.

    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 clean injection-site skin before administering injections

    Wider context from the report

    “The nurse who administered the injection gave evidence that she did not clean the skin prior to administering the injection. She did not do so because she was following both her training (she quoted from an NHS e-learning module on administering intramuscular injections) and national guidance in the form of a document titled “Immunisation Against Infectious Disease”, which is also referred to as “The Green Book”. Chapter 4 of “The Green Book” provides guidance on immunisation procedures. In relation to cleaning the skin the Green Book states as follows (at page 29): If the skin is clean, no further cleaning is necessary. Only visibly dirty skin needs to be washed with soap and water. It is not necessary to disinfect the skin. Studies have shown that cleaning the skin with isopropyl alcohol reduces the bacterial count, but there is evidence that disinfecting makes no difference to the incidence of bacterial complications of injections (Del Mar et al., 2001; Sutton et al., 1999). The evidence that I heard at the inquest included that alcohol wipes are relatively cheap and their use does not give rise to any significant risk. I note that the Green Book states that cleaning the skin with alcohol reduces the bacterial count. Common sense would seem to suggest that reducing the bacterial count would reduce the risk of bacteria being inadvertently introduced into the deeper tissues during an injection. Whilst it is noted that the Green Book also makes reference to there being evidence that disinfecting makes no difference to the incidence of bacterial complications, it is also noted that the literature quoted is now over 20 years old. ”

    Source location

    Patricia Heather Lines · 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

    Use the case as a learning exercise in clinical staff appraisals.

    Verbatim wording from the response

    “The Practice will take the following actions in order to prevent similar cases from occurring.”

    Source location

    Response from Browney House Surgery
    Page 1 · response
    Published 30 October 2024

    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

    Enrol clinical staff in Injection Administration Training to improve practical injection-administration competency.

    Verbatim wording from the response

    “The Practice will take the following actions in order to prevent similar cases from occurring.”

    Source location

    Response from Browney House Surgery
    Page 1 · response
    Published 30 October 2024

    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

    Follow current local and national guidance for injection administration and injection-site skin preparation.

    Verbatim wording from the response

    “The Practice will take the following actions in order to prevent similar cases from occurring.”

    Source location

    Response from Browney House Surgery
    Page 1 · response
    Published 30 October 2024

    Open published response

  4. Cornwall and Isles of Scilly

    AI-generated summary

    Raymond Claude Woodhouse · 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

    Raymond Claude Woodhouse had severe Parkinson’s disease and underwent a total knee replacement, after which he developed infections in his elbow and knee and died on 11 February 2019. Concerns included difficulties obtaining staff attention, poor cleanliness, a potential delay in antibiotics, and multiple late or omitted doses of prescribed Parkinson’s medication.

    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 cleanliness and failure to change soiled bedding and clothes

    Wider context from the report

    “ii) A lack of cleanliness with Mr Woodhouse being left in soiled bedding and clothes. It was not possible at inquest to come to a view that this was the cause of the infections in the knee and/or elbow. ”

    Source location

    Raymond Claude Woodhouse · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

  5. Manchester South

    AI-generated summary

    Irene Collins · 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

    Irene Collins, who had advanced dementia and other significant health problems, was found dead at her care home on 16 June 2018 with a latex clinical examination glove obstructing her upper airway. The principal concern was that clinical examination gloves were readily accessible to residents, including those with cognitive impairment, and could be disposed of in easily accessible bins.

    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 restrict residents’ access to bins containing used clinical examination gloves

    Wider context from the report

    “The court heard evidence that at Firbank House, there was unrestricted access to clinical examination gloves and other personal protective equipment intended to be used by those delivering care from wall-mounted dispensers in corridors. Additionally, at that time, once used the clinical examination gloves could be disposed of in a variety of bins, which were again easily accessible to residents. Whilst significant steps have now been undertaken at Firbank House to restrict the access of clinical examination gloves to residents with cognitive impairment, it is a matter of concern that in many settings where care is provided to vulnerable people, they are extremely easy to access. It is considered an alert or authoritative guidance as to the storage and disposal of clinical examination gloves in care settings may prevent future deaths. ”

    Source location

    Irene Collins · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

  6. Manchester South

    AI-generated summary

    William Gordon Tolen · 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

    William Gordon Tolen was living at Shawe Lodge when he developed problems with his legs and left great toenail; a podiatrist removed the toenail, after which he developed cellulitis. The investigation concluded that the death was from natural causes, with septicaemia and cellulitis recorded as the medical cause of death. Concerns included inadequate record-keeping, delays in arranging podiatry care, insufficient staff training, and the inappropriate conditions in which the procedure was carried out.

    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 a clean and appropriate setting for podiatry procedures

    Wider context from the report

    “8. The podiatrist carried out a procedure in the sitting room. She had to remove food debris and other detritus from around Mr Tolen’s feet before she could put down plastic sheets. This practice rendered both Mr Tolen and other residents at risk of infection and it was wholly inappropriate to carry out such a procedure in this way████████ ”

    Source location

    William Gordon Tolen · Prevention of Future Deaths report
    Page 1 · concerns

    Open source report

  7. Manchester West

    AI-generated summary

    Martin Leslie Dean · 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

    On 13 December 2013, Martin Leslie Dean suffered an intracerebral haemorrhage at home and was transferred to Salford Royal Hospital, where a shunt and feeding tube were inserted. The inquest concluded that he died as a consequence of a naturally occurring intracerebral haemorrhage together with a complication of necessary treatment. Evidence raised concerns that visitors to the Critical Care Ward were not washing their hands on entry, despite hand washing being identified as the most effective single precaution against infection.

    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 ensure that visitors wash their hands before entering Critical Care Wards

    Wider context from the report

    “During the Inquest evidence was given that a number of visitors to the Critical Care Ward where Martin Leslie Dean was a patient were not washing their hands on entering the ward. Further evidence stated that the most effective single precaution that could be taken to prevent infection was hand washing. The evidence continued by revealing that it would be possible to station volunteers at the entrances to wards particularly at the entrances to Critical Care Wards where patients might be especially susceptible to infection in order to ensure that visitors did not enter the wards without washing their hands. As volunteers could be used for this function, it was stated that it would be a precaution that could be achieved at little or no cost. ”

    Source location

    Martin Leslie Dean · Prevention of Future Deaths report
    Page 1 · 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