Recurring concern

Failure to maintain effective environmental cleaning in healthcare settings

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First reported 30 Apr 2021•Latest report 15 Dec 2023

Definition

What this concern includes

Includes failures of environmental cleaning in healthcare settings, including selecting or completing the required cleaning level, routine and deep cleaning, cleaning of shared or patient areas, and implementation or monitoring of cleaning standards where the deficiency creates an infection risk.

Not included

  • Excludes general infection-prevention, hygiene or housekeeping deficiencies where environmental cleaning is not the identified unsafe condition.
  • Excludes cleaning in domestic, leisure, industrial or other non-healthcare settings unless the assertion explicitly concerns a healthcare cleaning process.
  • Excludes failures limited to clinical treatment, personal hygiene, sterilisation of instruments or hand hygiene where environmental cleaning is not deficient.
  • Excludes generic staffing, training, policy or monitoring deficiencies unless they directly undermine healthcare environmental cleaning.
Reports
2

Distinct published reports

Individual concerns
2

A report can raise multiple concerns

Date range
2021–2023

First to latest report issue date

Stated actions
0

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.

Cambridge University Hospitals NHS Foundation Trust1
Ministry of Justice1
Worcestershire Acute Hospitals NHS Trust1

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.

  1. Worcestershire

    AI-generated summary

    Terence Edward Hines · 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

    Terence Edward Hines developed an MRSA infection after surgery for a fractured right neck of femur and died in hospital on 15 July 2023. The report identified failures to carry out the required Red clean of a hospital room and routine MRSA screening, and raised concerns about staff awareness of relevant policies and 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

    Failure to carry out the required Red clean of a room before a subsequent occupant moves in

    Wider context from the report

    “2) On 19.6.23 Mr. Hines was moved to side room 2, on ward 2 at the hospital. This room had been vacated that same day by another patient who had a known MRSA infection and an exfoliating skin condition which, taken together, represented a heightened risk of a subsequent occupant of the room developing an MRSA infection, and therefore ought to have triggered a Red ( hydrogen peroxide ) clean of the room before Mr. Hines moved into it; 3) A Red clean of the room did not take place before Mr. Hines moved into the room – instead, an Amber ( chlorine ) clean was carried out in error; ”

    Source location

    Terence Edward Hines · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

  2. Cambridgeshire and Peterborough

    AI-generated summary

    Alvin Roy Black · 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

    Alvin Roy Black, a serving prisoner, died after developing breathing difficulties and chest pains two days after returning from hospital spinal surgery. He suffered a fatal pulmonary embolism and cardiac arrest despite CPR. Concerns included poor hygiene in the prison Health Care Centre and a missed opportunity to review whether anti-coagulation therapy should have been provided after surgery.

    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 maintain adequate hygiene and deep cleaning in non-clinical Health Care Centre areas

    Wider context from the report

    “(1) Extensive evidence was heard concerning the poor state of cleanliness of the Health Care Centre at the Prison. Evidence confirmed that the ground floor of the Health Care Centre was not part of the clinical areas for which the Northamptonshire NHS Foundation Trust, the providers of health care at the Prison, were responsible: this area remained the responsibility of the Ministry of Justice. Whilst Health Care patients would regularly be located there, designated ‘vulnerable prisoners’ were also routinely resident in this location and, in respect of this cohort, there would be both a high turnover and sometimes challenging hygiene issues accompanying them. The evidence confirmed that the levels of hygiene in the common ways, kitchens, sinks, showers and the cells was poor and that this was of concern to prisoner patients and medical staff alike. Evidence also confirmed that no ‘deep cleans’ took place in these areas save where blood, vomit or a ‘dirty protest’ was specifically involved. I am concerned that such poor levels of hygiene give rise to the risk of prisoners returning from surgery, with perhaps compromised immune systems, facing a significant risk of infection, itself giving rise to a risk of future death. ”

    Source location

    Alvin Roy Black · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report
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Data last updated 7 September 2026