The Healthcare Commission has published a damning report on infection control at the Maidstone and Tunbridge Wells NHS Trust, which is believed to have led to an estimated 90 deaths due to C. difficile. The chief executive of the Trust, Rose Gibb, has stepped down and Health Secretary Alan Johnson has intervened to ensure her severance payment worth £250,000 is frozen. The police and the Health and Safety Executive are reported to be investigating further to see if criminal charges are appropriate against the Trust.
However, the Commission found that the board was unaware of the high infection rates and did not spend enough time considering issues relating to infection control.
The board did not address problems that were consistently raised by patients and staff. These included the shortage of nurses, poor care for patients and poor processes for managing the movement of patients from one ward to another, all of which contributed to the risk of spreading the infection.
Evidence from patients, staff and the Trust’s own records show that patients, including those with C. difficile, were often moved between several different wards, increasing the risk of spreading infection. In some instances this was blamed on meeting government target for waiting times for treatment in A&E wards. Other factors contributing to the outbreaks included old buildings, with few single rooms or side rooms to isolate patients. Moreover, beds were placed too close together, making it difficult to clean between them. In the second outbreak, an isolation ward was not established until August, four months after it began, and only half the clinical staff attended mandatory updates on infection control.
Nurses were often too rushed to clean their hands properly, empty and clean commodes, clean mattresses and equipment properly, or wear aprons and gloves appropriately and consistently. In fact, there was evidence of several occasions when nurses told patients to “go in their beds”, rather than assisting patients with diarrhoea to a commode or bathroom. The Trust has made a number of improvements as a result of the investigation. These include increasing space between beds; appointing a new director of infection prevention and control; implementing a new policy for prescribing antibiotics; and making a commitment to increase staff and training.
Most recent infection rates available from the Health Protection Agency show that rates of C. difficile more than halved at the Trust for the period January to March 2007, compared to January to March 2006.
Anna Walker, the Commission’s chief executive, said: “I urge all trusts to heed the lessons of this report so that they can look patients in the eye and say that everything possible is being done to protect people from infection.
“One thing this report really highlights is the importance of leadership. Infection control is not always prominent enough on the radar of some boards. Everybody – from managers to clinicians and cleaners – must understand their role. This will not happen effectively without commitment from the top.”
The Commission also recommended that the NHS and the Health Protection Agency agree clear and consistent arrangements for monitoring rates of C. difficile infection in the future.
