PFD report

Nicola MULLISS · Prevention of Future Deaths report

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Issued 4 Sep 2025•Newcastle and North Tyneside

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
1

Raised in this report

Recipients
1

Named on the report

Responses found
1

Of 1 recipient

Stated actions
2

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

Select any concern, action or position to view the source wording.

Concerns raised1

  1. Lack of policy or guidance for microbiological swabbing when re-suturing wounds
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.1

  1. Action

    Strengthen pathways for timely cultures, including wound swabs, and prompt antibiotics when infection is suspected.

    Stated by the Newcastle Upon Tyne Hospitals NHS Foundation TrustStated plannedThe respondent said that this action was planned when they made their response on 16 September 2025.

Respondent positions A position is what a recipient says about a concern when it does not describe a specific action.1

  1. Position

    Universal swabbing of leaking wounds is not clinically appropriate because leakage is often normal and positive cultures may cause unnecessary antibiotic use.

    Stated by the Newcastle Upon Tyne Hospitals NHS Foundation TrustDisputes the concernThe respondent disagreed with part of the concern or the basis for it.

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

Lack of policy or guidance for microbiological swabbing when re-suturing wounds

Wider context from the report

“In evidence I was told that had a swab been taken for microbiological analysis when the wound was re-sutured, it was possible that the Staphylococcus Aureus infection could have been detected at this earlier juncture and treatment investigated before the infection spread and resulted in the fatal staphylococcal meningitis. However, I was told that it is not policy / guidance for such testing to be undertaken so this did not occur. ”

Is this part of a recurring concern?

No recurring-concern membership is currently published.

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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

Strengthen pathways for timely cultures, including wound swabs, and prompt antibiotics when infection is suspected.

Verbatim wording from the response

“Following your correspondence, I can confirm that we will strengthen our pathways to ensure that when a patient is suspected of having an infection, appropriate cultures are undertaken in a timely manner, including wound swabs and that where clinically appropriate, patients are commenced promptly on antibiotics. Compliance with these standards is regularly monitored, and we will also consider additional ways to strengthen these safeguards.”

Source location

Response from Newcastle upon Tyne Hospitals NHS Foundation Trust
Page 2 · response
Published 16 September 2025

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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

Universal swabbing of leaking wounds is not clinically appropriate because leakage is often normal and positive cultures may cause unnecessary antibiotic use.

Verbatim wording from the response

“Having reviewed your comments, we can confirm that it is not clinically appropriate to take swabs of all leaking wounds. Wounds leak for a number of reasons, frequently as a result of the natural healing process. Serous or haemorrhous fluid leaks (as occurred”

Source location

Response from Newcastle upon Tyne Hospitals NHS Foundation Trust
Page 1 · response
Published 16 September 2025

Open published response

Other statements in published responses

These actions and other statements could not be clearly connected to one concern in this report.

Recipient-stated actions An action is something a recipient says it has done, is doing, or plans to do in response to a concern raised.1

  1. 1

    Consider additional ways to strengthen safeguards for suspected infections.

    Stated by the Newcastle Upon Tyne Hospitals NHS Foundation TrustStated plannedThe respondent said that this action was planned when they made their response on 16 September 2025.

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

Consider additional ways to strengthen safeguards for suspected infections.

Verbatim wording from the response

“Following your correspondence, I can confirm that we will strengthen our pathways to ensure that when a patient is suspected of having an infection, appropriate cultures are undertaken in a timely manner, including wound swabs and that where clinically appropriate, patients are commenced promptly on antibiotics. Compliance with these standards is regularly monitored, and we will also consider additional ways to strengthen these safeguards.”

Source location

Response from Newcastle upon Tyne Hospitals NHS Foundation Trust
Page 2 · response
Published 16 September 2025

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