An investigation by the Health and Safety Executive has supported senior managers' handling of a Clostridium difficile outbreak in which 33 people died.

The draft HSE report, seen by HSJ but not yet published, calls into question many of the findings of a 2006 Healthcare Commission investigation, which criticised managers at Buckinghamshire Hospitals trust.

The executive concludes the senior management team at Stoke Mandeville was 'fully engaged' in trying to prevent and control the outbreaks between October 2003 and June 2005.

In total, 334 patients contracted the infection. Senior managers were castigated by the commission for not learning the lessons from the earlier outbreak, and failing to implement proper isolation for patients who had contracted it.

In contrast, the HSE has not 'uncovered any evidence that senior managers abdicated their responsibilities in respect of these matters'.

The report states: 'Dealing with a developing situation, the trust took reasonably practicable steps in line with published guidance to control the outbreaks given the other priorities and constraints they were facing at the time.'


It also says the trust's performance was no worse than others, despite the attention it received.

'The challenges facing Buckinghamshire Hospitals trust were the same as those facing many other trusts. Their performance was comparable to their peers and in some respects better,' it says.

The investigation concludes that the 'weight of evidence is that trust did all that was reasonably practicable to ensure the health and safety of staff and patients'.

Former trust chief executive Ruth Harrison, who resigned after publication of the commission's report, told HSJ it had chosen to make Stoke Mandeville a 'scapegoat' and had come to the trust 'with the intention of finding us guilty'.

'I knew at the time of publication that a large proportion of the Healthcare Commission report was poorly researched and deeply biased.

'The slant put on the whole report by the commission was in my view an abject failure to publish a balanced report.'

Ms Harrison said she believed it was now time to shine an 'intense spotlight on the methodologies and motives of the commission'.

A Healthcare Commission spokeswoman said it would not comment on a leaked draft report. She added: 'It is however important to remember the facts. The Healthcare Commission's investigation was requested by the health secretary, who fully accepted our findings. The findings and recommendations have also been fully accepted by the trust. This whole process was necessary to protect the safety of patients.'

She also said it was 'important to recognise' the commission and the HSE have fundamentally different statutory duties and remits.

Agree to differ? The commission versus the HSE

On action

Healthcare Commission: 'The trust implemented some changes but none that might compromise their strategic objectives and not enough to reduce significantly the likelihood of a further outbreak.'

Health and Safety Executive: 'In dealing with a developing situation, the trust took reasonably practicable steps to control the outbreaks given the other priorities and constraints they were facing.'

On discussion

HC: 'There was no evidence of any discussion of outbreaks by the board in public until after they were reported in the press.'

HSE: 'While the lack of recorded discussion of the outbreaks indicates significant weakness in trust governance structure, witnesses have attested to considerable informal discussion, at all levels of management, of potential actions.'

On leadership

HC: 'The director of infection prevention and control did not provide appropriate direction and leadership.'

HSE: 'Interviews with the director of infection prevention and control revealed that he was in daily contact with the trust's chief executive and other trust directors.'