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Errors caused infection outbreak Superbug errors cause 90 deaths
(about 3 hours later)
A report has found a "litany" of errors in an NHS Trust's poor handling of the infection clostridium difficile, which resulted in 90 deaths. A "litany" of errors in an NHS Trust's poor handling of the infection clostridium difficile resulted in 90 deaths, a watchdog's report has found.
The deaths, over a two and a half year period, at Kent's Maidstone and Tunbridge Wells Trust was called "a tragedy" by the Healthcare Commission. The Healthcare Commission called the deaths at Kent's Maidstone and Tunbridge Wells NHS Trust "a tragedy".
Failings included a "targets obsession" and dire staff shortages. It said nurses at the trust were too rushed to wash hands and left patients to lie in their own excrement.
The trust's medical director said few trusts could have been prepared for "an outbreak of that size and complexity". The trust said it had not been prepared for "an outbreak of that size and complexity" but had learned lessons.
Kent Police and the Health and Safety Executive are examining the report. For many of these patients there may well have been a good chance that they would have recovered if all steps had been taken Heather WoodReport author class="" href="/1/hi/health/6252151.stm">Q&A: Clostridium difficile
They could decide to press criminal charges. Heather Wood, the report's lead author, told BBC Radio Five Live that many lives could have been saved.
The trust's chief executive, Rose Gibb, resigned last week. "I think it's certainly a call to arms for the National Health Service.
But the Healthcare Commission said despite her departure, nothing short of a full review of the trust's leadership would be appropriate in the circumstances. "I would think the lessons, not just about cleanliness, hygiene and infection control, but the care provided to patients who contract C.difficile is something that has wider lessons for the NHS.
'Improbable' claims "For many of these patients there may well have been a good chance that they would have recovered if all steps had been taken."
C.difficile is a bacterial infection of the gut which mainly affects the elderly. Police in Kent and the Health and Safety Executive are now investigating whether prosecutions should be brought over the deaths during a two-and-a-half-year period.
NURSES DID NOT ALWAYS Wash handsEmpty/clean commodesHelp patients go to toiletClean mattressesWear aprons/gloves class="" href="/1/hi/health/7038107.stm">'My mother died' Death rate
The commission began investigating amid a string of complaints, and was particularly alarmed after the trust claimed no-one had died of the condition despite admitting there had been hundreds of cases. The commission began its investigations amid a string of complaints about cleanliness, and was particularly alarmed after the trust claimed no-one had died from the condition despite admitting there had been hundreds of cases.
This seemed highly improbable given that the average death rate is between 6% and 7%.This seemed highly improbable given that the average death rate is between 6% and 7%.
It examined in detail a sample of 50 patients of a total of 345 to whom various causes of death had been attributed, but who were also known to have had C.difficile, between April 2004 and September 2006. Nigel Ellis, head of investigations at the Healthcare Commission, told BBC One's Breakfast: "The hospital trust didn't even pick up the first of the two outbreaks... wasn't aware that it was an outbreak at the time.
The commission looked at how these patients had been treated in the course of their stay, and tried to assess whether C.difficile contributed or was the main cause of their death. NURSES DID NOT ALWAYS Wash handsEmpty/clean commodesHelp patients go to toiletClean mattressesWear aprons/gloves class="" href="/1/hi/health/7038107.stm">'My mother died'
Extrapolating its findings from the sample, it concluded that C.difficile was definitely or probably the main cause of death for 90 patients. "And when the second outbreak came about, they were still not quick enough to act to take the steps that we would consider to be reasonable."
He said the commission concluded that "presumably their priorities were elsewhere".
He added: "There is no reason that the safety of patients in this way can be considered to be a secondary consideration."
The watchdog examined a sample of 50 patients out of a total of 345 to whom various causes of death had been attributed, but who were also known to have had C.difficile, between April 2004 and September 2006.
It concluded that C.difficile - a bacterial infection of the gut which mainly affects the elderly - was definitely or probably the main cause of death for 90 patients.
It was definitely a contributing factor in the deaths of a further 124, and a probable factor in another 55.It was definitely a contributing factor in the deaths of a further 124, and a probable factor in another 55.
How? Nurse shortages
The trust's chief executive, Rose Gibb, resigned last week.
But the Healthcare Commission said despite her departure, nothing short of a full review of the trust's leadership would be appropriate in the circumstances.
The commission described the trust as one which had been facing some "serious challenges", not least those brought on by a recent merger.The commission described the trust as one which had been facing some "serious challenges", not least those brought on by a recent merger.
Commodes were not properly cleaned after use
But it suggested that the board's fixation with meeting financial targets got in the way of making sure safety was a priority, and it accused members of not addressing problems consistently raised by patients and staff.But it suggested that the board's fixation with meeting financial targets got in the way of making sure safety was a priority, and it accused members of not addressing problems consistently raised by patients and staff.
Commodes were not properly cleaned after use
These included the shortage of nurses, which in turn led to poor care for patients.These included the shortage of nurses, which in turn led to poor care for patients.
For instance, nurses did not have time to wash their hands properly, and left patients to lie in their own excrement because they had not been able to assist them to a commode.For instance, nurses did not have time to wash their hands properly, and left patients to lie in their own excrement because they had not been able to assist them to a commode.
The report found that shortages were so dire that nurses told patients to "go in their beds".The report found that shortages were so dire that nurses told patients to "go in their beds".
Patients with C.difficile were moved between wards, increasing the risk of infection. In some instances this was due to concerns about meeting the government's targets for waiting times for treatment in A&E wards, the report said. Patients with C.difficile were also moved between wards, increasing the risk of infection.
In some instances this was due to concerns about meeting the government's targets for waiting times for treatment in A&E wards, the report said.
Isolation wards were few and far between, and sometimes the infected were simply kept in the middle of the ward.Isolation wards were few and far between, and sometimes the infected were simply kept in the middle of the ward.
This was in part the problem of managing a large, old hospital with "dormitory-style" wards where beds were very close together, making them very hard to clean between.
Saying sorrySaying sorry
The commission noted there were "worrying similarities" with the last serious C.difficile outbreak it had investigated at Stoke Mandeville, in which 30 patients died. The commission noted there were "worrying similarities" with the last serious C.difficile outbreak it had investigated at Stoke Mandeville hospital, in which 30 patients died.
MAIDSTONE AND TUNBRIDGE WELLS TRUST Maidstone HospitalKent and Sussex HospitalPembury HospitalMAIDSTONE AND TUNBRIDGE WELLS TRUST Maidstone HospitalKent and Sussex HospitalPembury Hospital
Both involved old hospitals, both had recently undergone mergers, and at both the boards were "preoccupied with finance".Both involved old hospitals, both had recently undergone mergers, and at both the boards were "preoccupied with finance".
The commission said NHS trusts across the country could learn lessons from both these examples. The commission is urging trusts to treat C.difficile as a condition in its own right, rather than a complicating factor.
Chief among its recommendations is a policy of treating C.difficile as a condition in its own right, rather than a complicating factor.
In addition, antibiotics should be used with utmost care in treating the condition, as they can easily make it worse by killing the so-called "friendly" bacteria in the gut which help the body fight it.In addition, antibiotics should be used with utmost care in treating the condition, as they can easily make it worse by killing the so-called "friendly" bacteria in the gut which help the body fight it.
Maidstone and Tunbridge Wells Trust said it welcomed the recommendations and said it was already beginning to implement them. Maidstone and Tunbridge Wells Trust welcomed the recommendations.
Medical director Dr Malcolm Stewart told BBC News: "I think like most other trusts in the United Kingdom, our trust just wasn't prepared for an outbreak of that size or complexity.Medical director Dr Malcolm Stewart told BBC News: "I think like most other trusts in the United Kingdom, our trust just wasn't prepared for an outbreak of that size or complexity.
"Certainly, no-one had experience managing such an outbreak."Certainly, no-one had experience managing such an outbreak.
"It was a steep learning curve but lessons were learnt.""It was a steep learning curve but lessons were learnt."
The government has pledged £140m to tackle C.difficile as part of the Comprehensive Spending Review.The government has pledged £140m to tackle C.difficile as part of the Comprehensive Spending Review.