When a consultant surgeon was found to be infected with hepatitis C, the worry was that he might have infected patients. The UK Advisory Panel for Healthcare Workers Infected with Bloodborne Viruses was informed and the panel launched a look-back exercise within 24 hours, in October 1999.
The infected doctor worked in the south of England, but had operated in the Dewsbury area for a time before 1989. By the time Dewsbury Health Care trust became involved, an initial exercise had been completed and had shown evidence of the transmission of infection from doctor to patient.
In the light of these findings a second referral was made to UKAP. Such was the advice to the deputy chief medical officer that it was considered necessary to extend the look-back to 1978.
In the late 1980s Dewsbury Health Care trust did not have a computerised theatre information system. So the only way former patients could be identified was to examine manually the theatre registers of all the theatres at that time, across two sites, and then manually trawl the details of the case notes. This was an enormous task with lessons for the whole of the NHS.
The chief executive and chair were fully briefed and a control team was set up. Forty trust staff were recruited to take part in the exercise.
The hospital's investigation was part of a national exercise, and confidentiality was crucial. A breach would have had an impact on other trusts and might have alarmed patients before support services were established.
The trust faced examining over 7,000 patient records. Only 11 people had a complete picture of what was involved - the control team and senior nursing and administrative staff involved in scrutinising the theatre registers and case-notes of former patients.
The control team met an average of three times a week until May this year.
The control room was in operation from late January until early April, and staffed from 7am to 8.30pm during the working week, and 8am to 5pm at weekends. It was only accessible to designated staff.
The examination of theatre registers and the trawl through case-notes and microfilmed records took 1,253 hours.
The cost of staff time to the trust was£19,000.
After examining over 7,000 records, 101 patients were identified as having undergone an exposure prone procedure by the surgeon.
This number was significantly higher than expected, given that the Department of Health instructed trusts to examine the records of all patients with the same name if other unique identifiers such as date of birth were not available to eliminate the patient from suspicion of exposure.
Four special clinics were arranged, each staffed by at least one member of the control team.
All patients were personally greeted, provided with counselling and given refreshments. They were then tested and asked whether they would like to receive their results by telephone or in person.
The control team arrangements and the liaison with NHS Direct worked well.
I maintained a file diary of all decisions throughout the look-back so that the trust would have evidence if they were ever asked to account for what was done.
This file diary, along with all other materials accrued, is now being stored for a minimum of 10 years on the advice of the DoH.
The use of e-mail greatly helped communication and the sharing of information with the regional office, the health authority, the other trust involved, NHS Direct and the public health laboratory in Leeds.
The quality of information developed for the press, booklets for patients and GPs and briefings for key players probably significantly reduced negative media exposure.
Patients commented on the professionalism of the trust. They appreciated the wording of the letter, the provision of telephone lines to seek additional information or to make an appointment for testing, the greeting they received, the counselling, and the fact that they were made to feel 'special'.
The briefing and debriefing arrangements provided an opportunity to inform a wider audience at exactly the same time as the national press release. It also provided an opportunity to offer recognition of the staff involved.
The arrangements for testing any members of staff identified as being at risk also went well. The occupational health department was able to see any staff who had been identified on the morning in which patients received their letters.
Lessons learned Much went well but there are lessons to be learned: in particular, the need to restrict the scope of the exposure-prone procedure list. On this occasion, the regional epidemiologist, informed by previous look-backs relating to HIV infection, provided a list which, with hindsight, included procedures that a junior surgeon in the late 1980s would not have carried out. Given that the trust was looking back 13 years, it would have been better to involve staff familiar with theatre practice at the time in screening the exposureprone procedure list from the start.
Also, we realised only after letters had been sent out to patients that regular blood donors are now routinely screened for hepatitis C. This would not have altered the need to inform patients of potential exposure. However, in future, the leaflet issued to patients should include a paragraph relevant to blood donors, reassuring them that they should not need recall testing.
It is important to discuss with the HA what arrangements are necessary in the event of detecting hepatitis C in a patient when there is no evidence of it having been transmitted by the surgeon.What treatment regime is to be offered, and how does that differ (if at all) from regimes being offered elsewhere in the country where other trusts are looking back? In future, these questions need to be answered centrally. Potential variations in treatment packages for any of the people involved in a national exercise of this type are not acceptable.
What advice do we have for other trusts involved in similar exercises?
Do not underestimate the size of the task ahead and be realistic about time-scales. Identify a lead person and a small control team and draw, where possible, on previous learning from other trusts and the regional office. Invest in that control team authority to delegate and make decisions.
Preserve confidentiality until ready to issue the press release. An exercise of this kind covering many years is fraught with difficulties. Do not attract attention where it is not needed.