Posted: 10/11/2007 4:02:05 AM EDT
|NHS hospital superbug outbreak kills 331|
By Rebecca Smith, Medical Editor
Last Updated: 8:53am BST 11/10/2007
Appalling standards of care and a catalogue of failures contributed to the deaths of 331 patients in the worst outbreak of a hospital superbug ever recorded in the NHS, a report has found.
Crowded wards, a shortage of nurses and financial problems led to 1,176 people contracting Clostridium difficile over two and half years at three hospitals in Kent.
Alan Johnson, the Health Secretary today described the failures as a "scandal", and said he would send the damning report to all hospital bosses in Britain so lessons would be learned.
Nurses did not have time to wash their hands
Though the superbug was rife on the wards, managers failed to act. Isolation units were not set up, nurses were so rushed they did not have time to wash their hands and patients were left in soiled beds.
Bedpans were not decontaminated properly and beds were not cleaned as well as they should have been.
The health watchdog, the Healthcare Commission, concluded that the infection probably or definitely killed at least 90 patients and was a factor in the deaths of a further 241.
Fourteen patients who died were found to have C.diff but it did not contribute to their deaths. In total 345 people died with the infection.
Mr Johnson told BBC Radio 4's Today programme that the Kent outbreak was an isolated incident, and not the result of hospital staff becoming preoccupied by Government targets.
"To suggest that in this particular incident, this reflects what's happening in the NHS across the country is absolutely wrong," he said.
"There are nurses and clinicians across the country who have dealt with the targets... but kept the highest safety standards."
The report said some patients at the hospitals run by the Maidstone and Tunbridge Wells NHS Hospital Trust should have made a full recovery from their initial illness. But they caught the bug and died. Police will determine if there are grounds for criminal charges.
In May 2004 the chief executive of the trust, Rose Gibb, told the BBC she had known about the cleanliness problem for six months. But by September last year the hospitals were in the grip of their second outbreak.
Ms Gibb resigned on Friday before the release of the report. The commission found cases where the patient probably died as a result of their C.diff infection but it was not mentioned on the death certificate.
The number of people who died also turned out to be far higher than declared to the media and the commission.
Last week the chief medical officer, Sir Liam Donaldson, wrote to all doctors telling them to ensure hospital infections were routinely included on death certificates. Gordon Brown has announced a raft of measures to improve cleanliness in the NHS.
The commission report said managers at Maidstone and Tunbridge Wells trust were too focused on hitting Government targets and were cutting nursing staff and closing beds to balance the books, contributing to the problem.
The first of two outbreaks affected 150 patients between October and December 2005. Even though the number of new cases doubled, managers did not notice.
A further 258 patients contracted C.diff in a second outbreak from April to September 2006 but an isolation ward to care for infected patients was not set up until four months into the outbreak.
At the time of the outbreaks, the trust was carrying out a programme to save £40 million over three years and the report said there was intense pressure to reduce beds.
It ended last year almost £5 million in the red.
The care of patients once they had contracted the infection was poor, they were given unsuitable medication and were often dehydrated or underfed.
The shadow health secretary, Andrew Lansley, said: "Centrally imposed waiting list targets have become such a burden on hospital staff that they have less time and fewer resources to protect patients."
Dr Malcolm Stewart, the medical director of Maidstone and Tunbridge Wells NHS Trust, said infection control had improved dramatically in the last six months.
He said: "We are sorry about what happened and are determined to continue to reduce levels of the infection."
55,634 people over the age of 65 were infected with C.diff last year in England.
1,170 patients were infected at Maidstone and Tunbridge Wells NHS Hospital Trust between April 2004 and September 2006.
331 the number of patients who died where c.diff was the main cause or at least a likely contributing factor in their death.
50 million pounds of extra funding to fight hospital infections was announced in July this year by ministers.
45 per cent of hospital trusts reported that Government targets got in the way of implementing infection control.
3 per cent of adults carrying clostridium difficile harmlessly in their gut.
1 billion pounds is the estimated cost of healthcare associated infections each year to the NHS.
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And Hillary says that Healthcare is a right? I'll take my chances claiming indigent status in a US hospital!