An NHS trust could face criminal charges over failures in its infection control measures that contributed to the deaths of 90 patients.
Every NHS trust in England will now get a copy of a damning report into failures at the Maidstone and Tunbridge Wells NHS Trust in Kent as a precautionary measure to highlight mistakes that occurred there. The Healthcare Commission, England's health watchdog, has just published its report after an investigation into outbreaks of Clostridium difficile at the trust's hospitals between April 2004 and September 2006.
The Healthcare Commission said that there were “significant failings” at the trust and that of 345 deaths it considered as part of its review 90 were “definitely or probably” caused by C difficile. The police and the Health and Safety Executive are now considering whether criminal charges should be brought against the trust over the deaths.
During the period under study more than 1170 patients were infected across the trust's three hospitals.
The report details several contributory factors, including:
Failure of the trust board to deal with problems raised consistently by patients and staff
Shortages of nurses, poor care of patients, and poor processes for managing movement of patients from one ward to another
Average rates of daily bed occupancy of more than 90% (and in some cases more than 100%) on medical wards where patients were not receiving surgery
High turnover of patients, limiting the time available to clean beds between patients, and
Outdated policies for preventing and managing infection.
The report's author, Heather Wood, said, “One of the things we would like to think the medical profession might pick up on particularly is our concern about the standards of basic medical care and management there, as well as the regular review of patients.”
Dr Wood said she had concerns about the general approach and attitude of staff to C difficile. “I would hope that this report would bring about a degree of sea change in the way in which doctors regard C difficile,” she said.
The report recommends that the trust board review its leadership (chief executive Rose Gibb has already resigned), prioritise infection control, improve standards of care, and increase levels of staff and training.
The trust's medical director, Malcolm Stewart, said, “We are sorry about what happened and we are determined to continue to reduce levels of the infection locally.” The trust had begun to implement the report's recommendations, he added, and was confident that patients were now treated in a safe environment.
The Healthcare Commission said that national lessons had to be learnt and that all NHS trust boards had to provide strong leadership in preventing and managing infection. It called for C difficile to be managed as a serious medical condition in its own right and not just a clinical complication.
Health secretary Alan Johnson told the BBC that the case was “scandalous” and that he would arrange for the report to be sent to all NHS trusts so they could learn lessons.
The trust has not confirmed speculation that Ms Gibb was given £250 000 as a pay-off the week before the report was published, saying that any contractual arrangements were “a private matter” between employer and employee.
Mr Johnson said, “I have instructed the trust to withhold any severance payment to the former chief executive of Maidstone and Tunbridge Wells NHS Trust, pending legal advice.”
The trust's chairman, James Lee, has also resigned.
Further reading
Clostridium difficileInvestigation into Outbreaks of at Maidstone and Tunbridge Wells NHS Trust is at www.healthcarecommission.org.uk