PFD report

Paul William BARBER · Prevention of Future Deaths report

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Issued 2 Mar 2017•Brighton and Hove

Report record

Published report and response evidence

This page connects the concerns raised in this report with statements found in recipients’ published responses. A link shows a clear evidence connection; it does not assign responsibility.

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Concerns
2

Raised in this report

Recipients
1

Named on the report

Responses found
1

Of 1 recipient

Stated actions
3

Described in responses

Recipients and published responses

Source document

Full report text

This is the full text from the original published report.

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Concerns and recipient responses

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Concerns raised2

  1. Delays in reporting important microbiology results to clinicians
    Part of recurring concern: Failure of microbiology testing services to provide timely and reliable resultsPart of recurring concern: Failure to ensure clinical investigation results are reliably available, interpreted and acted uponPart of recurring concern: Unreliable laboratory notification of safety-critical problems and results
  2. Failure to send microbiology samples in the correct containers
    Part of recurring concern: Failure of microbiology testing services to provide timely and reliable results
Responses linked to these concerns

Each statement is shown once, even when linked to more than one concern.

Actions described in response An action is something a recipient says it has done, is doing, or plans to do in response to a concern raised.3

  1. Action

    Discuss the delayed laboratory-result notification at a microbiology and infection clinical governance meeting as training for registrars prioritising urgent follow-up.

    Stated by University Hospitals Sussex NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 4 August 2017.
  2. Action

    Circulate Trust-wide guidance on submitting normally sterile body fluids in sterile white-capped containers rather than blood culture bottles.

    Stated by University Hospitals Sussex NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 4 August 2017.
  3. Action

    Alter the laboratory standard operating procedure to send educational advice when specimens arrive in incorrect containers.

    Stated by University Hospitals Sussex NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 4 August 2017.

Source evidence

How this individual concern was interpreted

PFD Monitor created a concise, searchable interpretation from the report wording shown below. Response links show a clear evidence connection; they do not assign responsibility.

PFD Monitor interpretation

Delays in reporting important microbiology results to clinicians

Wider context from the report

“(2) Delay in reporting important results to clinicians. On the 22nd July bacterial growth was detected in the bottles and gram staining showed gram positive cocci – this information was passed to the medical team looking after Mr Barber. On the next day, Saturday 23rd July, the laboratory found the same sample growing two organisms. This indicated that Mr Barber had a bacterial pericarditis – this was a very unusual situation and the identification of the organisms ought to have been given on the Saturday as soon as it was known to the medical team. For some reason the organisms were not reported until Tuesday 26th July shortly after Mr Barber’s death. Had these results been given appropriately on the 23rd July appropriate steps could have been taken to treat the patient with antibiotics. It is right to say that in this particular case on the balance of probabilities the two failings mentioned above did not affect the outcome – however it is right to report this so that these mistakes are highlighted and do not occur again either in this Hospital Trust or any other. ”

Is this part of a recurring concern?

Yes — Failure of microbiology testing services to provide timely and reliable results; Failure to ensure clinical investigation results are reliably available, interpreted and acted upon; Unreliable laboratory notification of safety-critical problems and results.

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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. Response links show a clear evidence connection; they do not assign responsibility.

PFD Monitor interpretation

Failure to send microbiology samples in the correct containers

Wider context from the report

“(1) Samples being sent to microbiology in the wrong containers and to elaborate on that Mr Barber had a recently diagnosed aggressive lung cancer on the back of which he developed pericarditis. By the 21st July 2016 it was clear that there was a collection of fluid around his heart which was susceptible to draining. This was done and sampling of the fluid was sent to the microbiologists for analysis. However, it was sent in the wrong container, this meant that it needed incubation before it could be dealt with giving a potential delay for results of between 24 – 48 hours. If it had been sent in the correct pot there is a good chance that full results would have been available the same day it was sent as the laboratory is open and testing until 7 p.m. ”

Is this part of a recurring concern?

Yes — Failure of microbiology testing services to provide timely and reliable results.

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

Discuss the delayed laboratory-result notification at a microbiology and infection clinical governance meeting as training for registrars prioritising urgent follow-up.

Verbatim wording from the response

“Concerning the delay in updating the clinicians caring for the patient about the new laboratory findings, the microbiology and infection department have discussed Mr Barber’s case in detail at their clinical governance meeting, as part of training for microbiology registrars to help them discriminate effectively in prioritising urgent follow up for appropriate specimens.”

Source location

Paul-Barber-Response
Page 1 · response
Published 4 August 2017

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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

Circulate Trust-wide guidance on submitting normally sterile body fluids in sterile white-capped containers rather than blood culture bottles.

Verbatim wording from the response

“In order to ensure that as many staff as possible learn from these events, a message has been circulated to all Trust staff reminding them that normally sterile body fluids, such as pericardial or ascitic fluid, should only be submitted to the laboratory in a sterile white capped container and not in a blood culture bottle. The same message made it clear that only blood and peritoneal dialysis fluid should be inoculated into blood culture bottles at the bedside. Secondly, the standard operating procedure within the laboratory has been altered so that, if such a specimen is received in the wrong container, an educational message is now sent advising on the correct container to be used in such circumstances so that the staff learn from this.”

Source location

Paul-Barber-Response
Page 1 · response
Published 4 August 2017

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

Alter the laboratory standard operating procedure to send educational advice when specimens arrive in incorrect containers.

Verbatim wording from the response

“In order to ensure that as many staff as possible learn from these events, a message has been circulated to all Trust staff reminding them that normally sterile body fluids, such as pericardial or ascitic fluid, should only be submitted to the laboratory in a sterile white capped container and not in a blood culture bottle. The same message made it clear that only blood and peritoneal dialysis fluid should be inoculated into blood culture bottles at the bedside. Secondly, the standard operating procedure within the laboratory has been altered so that, if such a specimen is received in the wrong container, an educational message is now sent advising on the correct container to be used in such circumstances so that the staff learn from this.”

Source location

Paul-Barber-Response
Page 1 · response
Published 4 August 2017

Open published response
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Information checked against the published report and official responses · Data reviewed 7 Sep 2026 · About data quality and limitations

Data last updated 7 September 2026