check the sanitation!



Hospital's focus on waiting time targets led to 41 superbug deaths

· Infection control failures listed by health inspectors
· NHS trust 'compromised safety of patients'

John Carvel, social affairs editor
Tuesday July 25, 2006
The Guardian

At least 41 pensioners were killed by a hospital superbug in the squalid wards of Stoke Mandeville because senior executives ignored the dangers and concentrated on delivering the government's waiting time targets, health inspectors warned yesterday.

Even after a public outcry prompted an investigation by the Healthcare Commission, the renowned hospital in Aylesbury failed to introduce basic measures of infection control. Earlier this year, when the NHS trust had supposedly corrected its mistakes, inspectors witnessed "dirty wards, dirty toilets and commodes, bedding and equipment lying on floors, faeces on bed rails, pubic hair in baths, mould and cobwebs in showers".

They went into the hospital to investigate three outbreaks of Clostridium difficile, a deadly bacterium that has infected 498 patients at Stoke Mandeville since October 2003. Anna Walker, the commission's chief executive, said there were "serious failings on the part of senior managers who did not follow advice on stopping the spread of infection". Members of the trust board "mistakenly prioritised other objectives such as the achievement of government targets, the control of finances and the reconfiguration of services".

The case was being considered last night by the Health and Safety Executive and Association of Chief Police Officers under an untried protocol for coordinating investigations into patient safety incidents. The protocol, signed in February, said the NHS would involve the police if there was "evidence or suspicion of gross negligence and/or recklessness in a serious safety incident, including as a result of a failure to follow safe practice or procedures". Speculation about the possibility of a corporate manslaughter charge was regarded by the authorities involved as premature.

The commission said C difficile can cause fatal inflammation of the walls of the intestine. It can be controlled by rigorous hygiene, rapid isolation of infected patients and avoidance of antibiotics that can lower the body's natural resistance to the bacterium's toxic effects.

Staff at Stoke Mandeville had difficulty adopting these techniques when the infection struck first in 2003, killing 16 people. There were few single rooms where patients could be isolated and the hospital suffered from "inadequate cleaning, lack of hand-washing facilities and a lack of training in infection control".

These failings should have been a wake-up call for the trust board. Instead it gave priority to the government's target for reducing waiting times in A&E departments to a maximum of four hours. "This led to some patients with infections being admitted or moved out of A&E within the target time into open wards rather than isolation facilities."

Patients were moved repeatedly from ward to ward, thereby spreading infection. A shortage of nurses "contributed to the spread of infection" because staff were "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". The commission said some of the cleaning practices it observed in the hospital were of "a completely unacceptable standard".

Ms Walker said the patients' deaths were an appalling tragedy. "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, she said. The trust's chief executive, chair of the board and chief nursing officer have all resigned since June. A recent blitz on cleanliness made the hospital one of the safest in England and patients need not be frightened, she insisted.

Stoke Mandeville hospital was previously best known for a pioneering spinal injuries unit and the charitable support of Sir Jimmy Savile. Tony Blair was taken there from Chequers when he experienced an irregular heartbeat in October 2003 - when the first C difficile outbreak started - but was taken for treatment to Hammersmith hospital in London.

Three years ago it became part of Buckinghamshire Hospitals NHS trust. Alan Bedford, the new chief executive, said the trust did not want to play down its responsibility, but patients could be reassured after an 80% reduction in cases of C difficile in the first six months of this year. The trust denied that the resignation of the three board members was connected with the

To add;
a big problem in hospitals
staph.from hospital to home
www.cbsnews.com
staph.takes a heavy toll on hospitals
www.medicine.net

The overuse of antibiotics for anything and everything in allopathic practices has caused staph. to mutate into a superbug.

Gina Tyler

__________________
"Great ideas often recieve violent opposition from mediocre minds"...................Einstein