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NHS superbug inquiry blames trust for deaths

Scores of NHS NHS
abbr.
National Health Service


NHS (in Britain) National Health Service
 patients were killed during Britain's deadliest outbreak of a hospital superbug su·per·bug
n.
Any of various disease-causing bacteria that develop a resistance to drugs normally used to control or eradicate them.



superbug
, a damning report by the government's health watchdog reveals today.

The Healthcare Commission The Healthcare Commission is an independent body, set up to promote and drive improvement in the quality of healthcare and public health in England and Wales. It aims to achieve this by becoming an authoritative and trusted source of information and by ensuring that this  attributed the deaths of 90 patients at the Maidstone and Tunbridge Wells hospitals in Kent to infection from Clostridium difficile Clostridium difficile A common cause of bacterial colitis; it is the causative agent in 99% of pseudomembranous colitis, and 20-30% of antibiotic-associated diarrhea , which causes severe diarrhoea and has taken over from MRSA MRSA Methicillin-resistant Staphylococcus aureus. See MARSA.  as the main threat to patients.

Evidence will be referred to Kent police and the Health and Safety Executive (HSE HSE House
HSE Health and Safety Executive
HSE Helsinki School of Economics
HSE Hamilton Southeastern (High School)
HSE Health, Safety & Environment
HSE Higher School of Economics (Moscow, Russia) 
) about how the trust's slack infection controls contributed to the deaths. They will decide whether to bring criminal charges, which could include murder, manslaughter or breaches of health and safety legislation, said Anna Walker, chief executive of the Healthcare Commission.

This week Alistair Darling, the chancellor, stepped up the fight against hospital-acquired infections Hospital-Acquired Infections Definition

A hospital-acquired infection is usually one that first appears three days after a patient is admitted to a hospital or other health care facility.
 by providing £140m in the comprehensive spending review to combat C difficile and £130m to screen all patients coming into hospital for MRSA.

But the commission said the evidence from Maidstone and Tunbridge Wells had national ramifications ramifications nplAuswirkungen pl . It said the cases showed the need for changes in clinical priorities and told the NHS to start treating C difficile as a diagnosis in its own right.

The report found 1,100 patients contracted C difficile at the trust's three hospitals between April 2004 and September 2006. A total of 345 mainly older patients with multiple medical problems died.

The commission concluded that 90 patients "definitely or probably" died as a result of infection. Sixty of these deaths occurred during two outbreaks when the trust failed to introduce adequate counter-measures - the most deadly case of superbug infection in NHS history.

Today's 124-page report blamed the trust's board for giving too much attention to balancing the books and meeting government waiting-time targets - and too little to service to patients and infection control. "Patients, including those with C difficile were often moved between several different wards, increasing the risk of spreading infection," it said.

The investigation began after the C difficile outbreaks, when the trust claimed to have corrected its infection control problems. But the inspectors took photographs of contaminated contaminated,
v 1. made radioactive by the addition of small quantities of radioactive material.
2. made contaminated by adding infective or radiographic materials.
3. an infective surface or object.
 bedpans, overflowing buckets of needles and sharp instruments, and food stored in medical refrigerators .

The commission said the trust failed to protect patients because the board was unaware of the first outbreak and was slow to react to the second. The government produced a hygiene code for all trusts in October, but the Maidstone board did not discuss it until March. Ms Walker said: "What happened to the patients was a tragedy ... Our inspections suggest infection control is not always prominent enough on the radar of some boards."

The trust said Rose Gibb, its chief executive since 2003, stepped down last week "by mutual agreement". Glenn Douglas, her interim replacement, has promised a zero tolerance The policy of applying laws or penalties to even minor infringements of a code in order to reinforce its overall importance and enhance deterrence.

Since the 1980s the phrase zero tolerance has signified a philosophy toward illegal conduct that favors strict imposition of
 approach to infection.

Malcolm Stewart, medical director of the trust, apologised for the tragedy, but could not explain why the hygiene code had been left off the board agenda for five months. He said rates of C difficile in the trust were lower than the NHS average last year.

Peter Carter, general secretary of the Royal College of Nursing The Royal College of Nursing (RCN) is a membership organisation with over 395,000 members in the United Kingdom. It was founded in 1916, receiving its Royal Charter in 1928, Queen Elizabeth II is the patron. , said: "We can only hope that patient care will never be compromised in this way again."

Andrew Lansley, the Conservative health spokesman, said he was shocked by the report and blamed "centrally imposed waiting list targets" for diverting resources away from the protection of patients.

The Liberal Democrat health spokesman, Norman Lamb, echoed the sentiments about targets.

Ann Keen, the health minister, offered her condolences to the patients and their families and said: "This type of failure must not be repeated."
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Author:guardian.co.uk
Publication:guardian.co.uk
Date:Oct 11, 2007
Words:604
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