Hospital criticised for bug outbreak

Hospital bosses at Stoke Mandeville Hospital in Buckinghamshire have been criticised for failing to control the spread of a deadly bug which resulted in at least 33 deaths.

The Healthcare Commission report investigated two outbreaks of Clostridium Difficile - a hospital-based infection which causes diarrhoea, but can also lead to more serious infections - at the hospital between October 2003 and June 2005.

The report was ordered by Health Secretary Patricia Hewitt.

The report said that managers had failed to learn any lessons from the first outbreak of the infection and blamed them for failing to follow advice on stopping the spread of infection. The report also blamed managers for focusing more on government targets, during the second outbreak in 2005.

Anna Walker, Healthcare Commission Chief Executive, said: "At Stoke Mandeville, the leadership of the trust compromised the safety of patients by failing to make the right decisions, even though they had the benefit of experience from the first outbreak. They rejected the proper advice of their own experts.

"Let me also be clear that targets are not to blame for the Trust's leaders taking their eye off the ball. Managers always have to deal with conflicting priorities and plenty of organisations do it successfully.

"We fully recognise that these outbreaks are not easy to control. But we also know that trusts can minimise the spread of infection so long as they follow established advice on infection control."

The report cited the major cause of the spread of the infection as a failure to isolate patients with the infection, instead keeping them on open wards. The movement of patients between wards was also cited as a factor.

The report also blamed a number of other factors including poor layout of older wards, inadequate cleaning, a lack of hand washing facilities, and a lack of training in infection control, as well as a shortage of nurses.

Staff on ward told investigators that they were "too rushed" to answer bell calls or change soiled sheets. They also did not take basic precautions, such as washing their hands, donning aprons and gloves consistently or even properly cleaning mattresses and equipment.

Patients and relatives had also complained to the Commission about poor hygiene, including dirty wards, toilet areas and commodes.

The Commission made a series of recommendations to the Trust, including: reviewing the criteria for transferring patients between wards, so that acutely ill patients were not placed on inappropriate wards; conducting a review of the way the board becomes aware of and considers clinical risk; and ensuring that wards are properly cleaned and that infection control is prioritised at all levels.

A total of 334 patients became infected with Clostridium Difficile during their stay at Stoke Mandeville and at least 33 died between October 2003 and June 2005.

Ms Walker said: "This is a sad and distressing story. It is a tragedy for the families, for the hospital and for the NHS as a whole."

(KMcA/SP)