Recurring concern

Failure to reliably provide required MRSA screening

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First reported 5 Oct 2020•Latest report 15 Dec 2023

Definition

What this concern includes

Includes failures in the healthcare MRSA-screening process to identify patients requiring screening, arrange and complete screening at required inpatient, admission, pre-operative or other clinically indicated points, and ensure the result is available for appropriate infection-prevention action.

Not included

Excludes general infection-prevention, hygiene, isolation or treatment failures where MRSA screening is not the deficient control.
Excludes failures involving other organisms or screening programmes unless the assertion explicitly concerns the same MRSA-screening process.
Excludes delays or omissions in acting on an MRSA result after screening was reliably completed.
Excludes generic documentation, staffing or communication deficiencies that do not directly impair required MRSA screening.

Reports: 2
Individual concerns: 2
Date range: 2020–2023
Stated actions: 1

Reports over time

Reports about this concern issued each year.

* 2026 is projected from reports observed to 7 Sep 2026.

Most frequent recipients

Reports about this concern sent to each recipient.

Greater Manchester Health and Social Care Partnership1

Health Services Safety Investigations Body1

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.

15 Dec2023
Worcestershire
Concerns raised1
1. Failure to carry out required routine MRSA screening
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.
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 required routine MRSA screening
Wider context from the report
“5) On or about 24.6.23, because Mr. Hines had now been an inpatient for 28 days, he should have been screened for MRSA. That routine MRSA screen was not carried out. The Trust’s investigation was unable to explain why that routine screen had not been carried out; 6) On 26.6.23 Mr. Hines suffered an accidental fall in the room, and was found to have sustained a fractured right neck of femur. As a result, he was transferred to Worcestershire Royal Hospital where surgery to fix the neck of femur fracture was carried out on 1.7.23; 7) As a matter of established routine, Mr. Hines should again have been screened for MRSA prior to his surgery,. Once again, that routine MRSA screen was not carried out. The Trust’s investigation did not explore the question of why that routine MRSA screen had not taken place; ”
Source location
Terence Edward Hines · Prevention of Future Deaths report
Page 2 · concerns
Open source report
5 Oct2020
Manchester South
Concerns raised1
1. Failure to routinely swab orthopaedic surgery patients from care homes or with previous positive MRSA results on hospital admission
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
Actions described in response 1
1. Action
  Share learning with infection prevention and control networks for dissemination to provider organisations and consideration of wider regional sharing.
  Stated by NHS Greater Manchester Integrated Care BoardStated planned
Respondent positions 2
1. Position
  Responsibility for addressing the concern about MRSA swabbing requirements is left to HSIB as the named respondent.
  Stated by NHS Greater Manchester Integrated Care BoardRedirects responsibility
1. Position
  HSIB will not investigate because its limited annual investigation capacity requires selecting issues with the greatest potential for new NHS learning.
  Stated by Health Services Safety Investigations BodyUnable to act
AI-generated summary

Joan Margaret Sanderson · 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

Joan Margaret Sanderson died at Tameside General Hospital on 15 June 2020 after an accidental fall, surgery for a left hip fracture, and a subsequent MRSA infection. The principal concern was that an MRSA swab was not routinely collected on admission for orthopaedic patients from care homes or with a previous positive MRSA result, which could have enabled earlier identification 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 routinely swab orthopaedic surgery patients from care homes or with previous positive MRSA results on hospital admission
Wider context from the report
“The inquest heard evidence from the Trust that following her death they had carried out a RCA to understand what learning could be taken from Mrs Sanderson’s death. A key piece of learning was identified, as patients being admitted for orthopaedic surgery, from a care home or those that have had a previous positive MRSA result should have a routine swab sent for MRSA on admission to hospital. In this case a swab was not collected as that was not standard at that time. Surgery would not be held up awaiting the outcome but it would have allowed earlier identification of MRSA which could impact the outcome in another case where emergency surgery is required and there is an infection post operatively. Patients admitted for elective surgery have a MRSA swab collected 12 weeks prior and receive decolonisation treatment for a positive MRSA result prior to surgery. The inquest was told this change had been rolled out in the trust and was seen as wider learning that could prevent future deaths within the NHS. ”
Source location
Joan Margaret Sanderson · 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
Share learning with infection prevention and control networks for dissemination to provider organisations and consideration of wider regional sharing.

Verbatim wording from the response
“3. Learning to be shared with the Greater Manchester Infection Prevention and Control Collaborative for members to take into their provider organisations to ensure that national screening guidance is being followed. Findings to be also shared with the Northwest NHS England/Improvement Infection prevention for consideration of sharing across the Northwest”

Source location
2020-0198-Response-from-GM-Health-and-Social-Care-Partnership-and-Healthcare-Safety-Investigation-Branchwillbe.pdf
Page 2 · response
Published 27 November 2020
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
Responsibility for addressing the concern about MRSA swabbing requirements is left to HSIB as the named respondent.

Verbatim wording from the response
“Following the inquest you raised concerns in your Regulation 28 Report to NHS England regarding that there was no requirement for MRSA swabbing of patients being admitted for orthopaedic surgery, from a care home or those that have had a previous positive MRSA result. Whilst surgery would not have been delayed awaiting the outcome of the results, it could impact the outcome in another case where emergency surgery is required and there is an infection post-operatively.”

Source location
2020-0198-Response-from-GM-Health-and-Social-Care-Partnership-and-Healthcare-Safety-Investigation-Branchwillbe.pdf
Page 1 · response
Published 27 November 2020
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
HSIB will not investigate because its limited annual investigation capacity requires selecting issues with the greatest potential for new NHS learning.

Verbatim wording from the response
“Following careful consideration, we will not be taking forward an investigation into your concerns. We are only able to undertake a limited number of national investigations each year, and therefore try to focus on those with the most potential for new learning across the NHS. The National Criteria for selection is described on our website: https://www.hsib.org.uk/public-patients/how-we-decide-to-investigate/”

Source location
2020-0198-Response-from-GM-Health-and-Social-Care-Partnership-and-Healthcare-Safety-Investigation-Branchwillbe.pdf
Page 3 · response
Published 27 November 2020
Open published response

Data last updated 7 September 2026

What this concern includes

Not included

Reports over time

Concerns raised1

Failure to carry out required routine MRSA screening

Concerns raised1

Failure to routinely swab orthopaedic surgery patients from care homes or with previous positive MRSA results on hospital admission

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

Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.2

Actions described in response 1

Respondent positions 2