SERIOUS failings by senior managers allowed Stoke Mandeville Hospital in Buckinghamshire to become the site of one of the worst episodes of superbug infection, resulting in the deaths of 65 patients, an official report has revealed.
The Healthcare Commission, the health inspectorate, said yesterday that an unacceptable disregard for basic hygiene and inexcusable inaction by managers was behind two major outbreaks of Clostridium difficile.
The highly critical report, which detailed a catalogue of hygiene offences including faeces on bed rails and patients’ clothes kept on the floor, concluded that managers had failed to learn from the first outbreak of the bug, which resulted in the deaths of 16 people.
A second outbreak, a year later in 2005, was not brought under control and another 17 people died. Over three years, 41 deaths were caused by C. difficile and it contributed to a further 24 deaths, investigators found. Most of those who died at Stoke Mandeville, in Aylesbury, were elderly and left on open wards instead of being moved into isolation. A lack of single rooms, unisex toilets and poor hygiene all led to the spread of the bug.
But the commission was particularly critical of Buckinghamshire Hospitals NHS Trust, saying that senior managers mistakenly prioritised government targets, such as a maximum waiting time of four hours in Accident and Emergency, and did not listen to staff. They also failed to listen to serious concerns raised by hospital infection experts, who asked for isolation facilities.
The emergence of C. difficile, which causes severe diarrhoea and can lead to potentially fatal inflammation of the gut, was made worse by a shortage of nurses, which left staff “too rushed to take basic precautions such as washing their hands, wearing aprons and gloves consistently, emptying commodes promptly and cleaning mattresses and equipment properly”.
Staff also told investigators that they were “too rushed to answer call bells or change soiled sheets”, the commission said. In all, 334 patients were infected with C. difficile during their stay at the hospital. The report said that utility rooms were cluttered with linen and waste bags, which meant that nurses could not reach washbasins. Head nurses and other senior staff were so worried about the standard of care and risks to patients that they wrote to the trust’s chief executive but “these concerns were not acted upon”.
Describing the situation as a tragedy, Anna Walker, chief executive of the Healthcare Commission, said that competing priorities, including targets, the control of finances and the reconfiguration of services, meant that trust managers “took their eye off the patient safety ball”.
“This is a sad and distressing story. It is a tragedy for the families, for the hospital and for the NHS as a whole . . . It is crucial that lessons are learnt from this report across the healthcare sector as a whole.”
Commission officials found that workers at the hospital did not clean equipment between patients, staff were poorly trained in hygiene and there was insufficient space to isolate patients with infections. This isolation policy, crucial to limiting the spread of disease, was not implemented for more than a year after alerts were first issued.
A further unannounced visit by commission investigators, in December, found yet more evidence of extremely poor practice, including bedding and equipment lying on floors, patients’ belongings kept in sacks on the floors instead of lockers, dirty wards and toilets, faeces on bedrails, pubic hair in the baths, mould and cobwebs in the showers and soiled commodes.
The commission has now made a series of recommendations to the trust, which must be implemented within 60 days. The former chief executive, Ruth Harrison, and former chairman, Andrew Croisdale-Appleby, have since resigned. The trust said yesterday that this was not a result of the report.
The trust’s acting chief executive, Alan Bedford, who has been in post for just over a week, said that C. difficile infections from January to June this year were down by 80 per cent on the same period last year.
“We are determined to learn everything we can from the report, and fully accept the Healthcare Commission’s recommendations that the outbreaks should have been handled better, and that there are organisational issues on which work is needed,” he said. “We cannot undo what has happened but we will do our very best to minimise incidents of hospital-acquired infections in the future and, when it does occur, to minimise its spread.”
MAIN CULPRITS
Clostiridum difficile is a spore-forming bacterium, which is present as one of the “normal” bacteria in the gut of up to 3 per cent of healthy adults. C. difficile is much more common in babies — up to two thirds of infants may have it in the gut, where it rarely causes problems. People over 65 are more susceptible to infection. It can cause illness when certain antibiotics disturb the balance of normal bacteria. Its effects can range from nothing in some cases to diarrhoea or severe, life-threatening, inflammation of the bowel
Methicillin-resistant Staphylococcus aureus is a bacterium that is commonly found on human skin and mucosa (lining of mouth, nose etc). The bacterium lives harmlessly on the skin and in the nose of about one third of healthy people. Staphylococcus aureus can cause actual infection and disease, particularly if there is an opportunity for the bacteria to enter the body, through a cut or an abrasion, for example. MRSA is a variety of the bug that is resistant to methicillin and some other antibiotics.
Glycopeptide-resistant Enterococci. Enterococci are commonly found in the bowels of most people. There are many different species, but only a few can cause infections in humans — 95 per cent of infections are caused by Enterococcus faecium and Enterococcus faecalis. These species are the two most common strains of GRE, which are resistant to glycopeptide antibiotics (vancomycin and teicoplanin). GRE commonly cause wound infections, blood poisoning and infections of the abdomen and pelvis.
