Trust may be prosecuted after hospital bug outbreak kills 33

[Guest guest]

24 July 2006 22:56 Home > News > UK > Health Medical

Trust may be prosecuted after hospital bug outbreak kills 33

By nce, Health Editor

Published: 25 July 2006

http://news.independent.co.uk/uk/health_medical/article1195258.ece

An NHS trust may be prosecuted for negligence after a lethal

hospital bug killed at least 33 patients and infected 334 over two

years.

A damning report into two outbreaks ofClostridium difficile at Stoke

Mandeville Hospital, Buckinghamshire, severely criticised managers

for repeatedly ignoring warnings from infection-control specialists.

They failed to follow advice from doctors, nurses and the Health

Protection Agency (HPA) on stopping infection because

they " mistakenly prioritised " other objectives such as hitting

government targets and curbing spending, the report said. The

Healthcare Commission, which carried out the inquiry, yesterday

ordered every NHS hospital in England to review infection control

procedures urgently in light of the findings.

National figures, published yesterday by the HPA, show cases of C.

difficile infection rose 17.2 per cent to 51,690 in 2005. Six out of

10 NHS trusts saw their infection rate rise last year.

The Department of Health said the chief medical officer and chief

nursing officer would review the inquiry report and consider how the

recommendations should be implemented across the country " because of

its wider application to the health service " .

The inquiry has already claimed the heads of three senior managers

at Buckinghamshire Hospitals NHS Trust, which runs Stoke Mandeville

and two other hospitals. Ruth on, the chief executive, and

Croisdale-Appleby, the chairman, resigned last week.

Kirk, the medical director who was also responsible for infection

control at the hospital, will leave in a few months, the trust said

yesterday.

Owing to the number of deaths and the failure of management, the

Healthcare Commission has for the first time sent its report to the

Health and Safety Executive, which has the power to prosecute

organisations under the Health and Safety at Work Act.

, the chief executive of the Healthcare Commission,

said: " There is a question whether there are prosecuting powers

which should be looked at in relation to this case. "

The report into Stoke Mandeville, which suffered the worst outbreak

of C. difficile in the country, said it was a " tragedy " which could

have been avoided. Lessons from the first outbreak, which lasted

from October 2003 to June 2004, affecting 174 patients and causing

16 deaths, were not learnt before a second outbreak from October

2004 to June 2005 claimed another 17 lives.

The key factor was a failure to isolate infected patients but

inadequate cleaning, lack of hand-washing facilities and poor state

of wards contributed. Even after the second outbreak, when

inspectors returned in December last year, they found faeces on bed

rails, pubic hairs in baths, mould and cobwebs around showers and

soiled commodes.

Ms said: " There were serious management failures ... They did

not apply the lessons from the first outbreak until pressure came

from outside led by The Independent. "

She denied waiting time targets were to blame, saying all managers

had to deal with conflicting priorities.

But the report records a meeting at the hospital on 24 March 2005 at

which the director of operations told a consultant in infection

control who raised concerns about C. difficile that targets must be

met " whatever the cost " . In the foreword to the report, Sir Ian

Kennedy, the commission's chairman, says: " Senior managers

concentrated too much on one responsibility - meeting targets for

waiting times. "

Lidington, Tory MP for Aylesbury, said: " What runs all through

this report is that managers were putting central targets ahead of

anything. "

Andy Burnham, the health minister, said powers in the new Health Act

would be used to deal with NHS trusts that failed to follow good

practice in controlling infections.

Buckinghamshire Hospitals NHS Trust has been given 60 days by the

Healthcare Commission to " improve patient safety " . Alan Bedford, the

acting chief executive, said infection rates from January to June

were down by 80 per cent on the same period last year.

* Cases of MRSA fell slightly in 2005 to 7,087 but it was too early

to say they were on a downward trend, the Health Protection Agency

said. They were falling too slowly to reach the government target of

a 50 per cent reduction by 2008.

'Independent' report prompted inquiry

A two-line e-mail arrived at The Independent in June 2005. It said

there had been an outbreak of a new strain of Clostridium Difficile

at Stoke Mandeville hospital with a death rate that was higher than

normal.

Everyone knew about MRSA but few had heard of C Difficile. Yet it is

the commonest cause of diarrhoea in hospitals and causes more than

2,000 deaths a year, twice as many as MRSA . It chiefly affects the

elderly and cases had been rising for a decade, from fewer than

10,000 in the mid 1990s to more than 50,000 last year.

Eight days after The Independent revealed the outbreak at Stoke

Mandeville on its front page on 6 June 2005, above, Hewitt,

the Health Secretary ordered an inquiry by the Healthcare

Commission. Yesterday's report says that managers at the hospital,

who had ignored warnings about the infection, only responded under

outside pressure. " It took the involvement of the Department of

Health and national publicity to change their perspective, " it said.

The report leaves unanswered the question of whether other trusts

may be taking similar risks. Professor Borriello, the director

of the Centre for Infections at the Health Protection Agency, said

he could not rule out the possibility that the situation at Stoke

Mandeville was being repeated elsewhere.

An NHS trust may be prosecuted for negligence after a lethal

hospital bug killed at least 33 patients and infected 334 over two

years.

A damning report into two outbreaks ofClostridium difficile at Stoke

Mandeville Hospital, Buckinghamshire, severely criticised managers

for repeatedly ignoring warnings from infection-control specialists.

They failed to follow advice from doctors, nurses and the Health

Protection Agency (HPA) on stopping infection because

they " mistakenly prioritised " other objectives such as hitting

government targets and curbing spending, the report said. The

Healthcare Commission, which carried out the inquiry, yesterday

ordered every NHS hospital in England to review infection control

procedures urgently in light of the findings.

National figures, published yesterday by the HPA, show cases of C.

difficile infection rose 17.2 per cent to 51,690 in 2005. Six out of

10 NHS trusts saw their infection rate rise last year.

The Department of Health said the chief medical officer and chief

nursing officer would review the inquiry report and consider how the

recommendations should be implemented across the country " because of

its wider application to the health service " .

The inquiry has already claimed the heads of three senior managers

at Buckinghamshire Hospitals NHS Trust, which runs Stoke Mandeville

and two other hospitals. Ruth on, the chief executive, and

Croisdale-Appleby, the chairman, resigned last week.

Kirk, the medical director who was also responsible for infection

control at the hospital, will leave in a few months, the trust said

yesterday.

Owing to the number of deaths and the failure of management, the

Healthcare Commission has for the first time sent its report to the

Health and Safety Executive, which has the power to prosecute

organisations under the Health and Safety at Work Act.

, the chief executive of the Healthcare Commission,

said: " There is a question whether there are prosecuting powers

which should be looked at in relation to this case. "

The report into Stoke Mandeville, which suffered the worst outbreak

of C. difficile in the country, said it was a " tragedy " which could

have been avoided. Lessons from the first outbreak, which lasted

from October 2003 to June 2004, affecting 174 patients and causing

16 deaths, were not learnt before a second outbreak from October

2004 to June 2005 claimed another 17 lives.

The key factor was a failure to isolate infected patients but

inadequate cleaning, lack of hand-washing facilities and poor state

of wards contributed. Even after the second outbreak, when

inspectors returned in December last year, they found faeces on bed

rails, pubic hairs in baths, mould and cobwebs around showers and

soiled commodes.

Ms said: " There were serious management failures ... They did

not apply the lessons from the first outbreak until pressure came

from outside led by The Independent. "

She denied waiting time targets were to blame, saying all managers

had to deal with conflicting priorities.

But the report records a meeting at the hospital on 24 March 2005 at

which the director of operations told a consultant in infection

control who raised concerns about C. difficile that targets must be

met " whatever the cost " . In the foreword to the report, Sir Ian

Kennedy, the commission's chairman, says: " Senior managers

concentrated too much on one responsibility - meeting targets for

waiting times. "

Lidington, Tory MP for Aylesbury, said: " What runs all through

this report is that managers were putting central targets ahead of

anything. "

Andy Burnham, the health minister, said powers in the new Health Act

would be used to deal with NHS trusts that failed to follow good

practice in controlling infections.

Buckinghamshire Hospitals NHS Trust has been given 60 days by the

Healthcare Commission to " improve patient safety " . Alan Bedford, the

acting chief executive, said infection rates from January to June

were down by 80 per cent on the same period last year.

* Cases of MRSA fell slightly in 2005 to 7,087 but it was too early

to say they were on a downward trend, the Health Protection Agency

said. They were falling too slowly to reach the government target of

a 50 per cent reduction by 2008.

'Independent' report prompted inquiry

A two-line e-mail arrived at The Independent in June 2005. It said

there had been an outbreak of a new strain of Clostridium Difficile

at Stoke Mandeville hospital with a death rate that was higher than

normal.

Everyone knew about MRSA but few had heard of C Difficile. Yet it is

the commonest cause of diarrhoea in hospitals and causes more than

2,000 deaths a year, twice as many as MRSA . It chiefly affects the

elderly and cases had been rising for a decade, from fewer than

10,000 in the mid 1990s to more than 50,000 last year.

Eight days after The Independent revealed the outbreak at Stoke

Mandeville on its front page on 6 June 2005, above, Hewitt,

the Health Secretary ordered an inquiry by the Healthcare

Commission. Yesterday's report says that managers at the hospital,

who had ignored warnings about the infection, only responded under

outside pressure. " It took the involvement of the Department of

Health and national publicity to change their perspective, " it said.

The report leaves unanswered the question of whether other trusts

may be taking similar risks. Professor Borriello, the director

of the Centre for Infections at the Health Protection Agency, said

he could not rule out the possibility that the situation at Stoke

Mandeville was being repeated elsewhere.