A Kent trust has been slated by the Healthcare Commission for failing to protect patients against infection.
In its investigation into Clostridium difficileoutbreaks at Maidstone and Tunbridge Wells trust, the commission says the infection was the likely cause of up to 90 deaths in two and a half years. It is likely to have contributed to 180 others in that time.
The report says C difficile was the definite or probable cause of death of 90 people from April 2004 to September 2006 - 60 of which were from October 2005 to September 2006, when the trust had two outbreaks. The commission examined a cross-section of cases and extrapolated its results to cover other affected patients.
The report, published today, calls on the trust board to review the leadership of the trust in the light of ‘significant failings’.
Rose Gibb, trust chief executive since 2003, resigned last week. The trust says that this was by mutual agreement with chair James Lee.
The report paints a picture of a trust driven by the need to meet financial and access targets, where warnings about the standards of care and risks to patients were not adequately acted on.
Ms Gibb was seen as ‘difficult to challenge’ by some people and controlled what information went to the board. The board was sometimes given inaccurate or incomplete information.
While the trust struggled with unsuitable buildings, issues with general cleanliness and hygiene arose repeatedly.
The trust had relatively low nursing levels and was trying to limit the use of bank and agency nurses to save money.
The handling of the outbreaks was also criticised, with infected patients left on wards, inadequate isolation policies and failings in basic care.
However, the commission does not blame the trust for all the deaths and says many would have occurred anyway.
The report also highlighted the role of other organisations. Primary care trusts had ‘given little attention to the quality of care or the control of infection’.
And the Health Protection Unit - part of the Health Protection Agency - is said to have generally worked in a reactive way, rather than supervising or monitoring infection control.
The trust said it is already implementing the recommendations in the report and that patients in its three hospitals - in Maidstone, Tunbridge Wells and Pembury - are now treated in a safe environment.
Interim chief executive Glenn Douglas said: ‘I am not complacent and I will lead the drive to continue to improve care for patients.’
Medical director Malcolm Stewart said: ‘We are very sorry that patients died and we are absolutely determined to bear down on this infection.’
Action taken by Maidstone and Tunbridge Wells trust includes changes to antibiotic prescribing; treating patients with the infection in isolation; improving cleaning; and putting an infection control report on every public board agenda.
It says it will also employ more nurses.
Ms Gibb is married to Barking, Havering and Redbridge Hospitals trust chief executive Mark Rees, who resigned in an unconnected incident last week. Mr Rees stood down just a week after asking staff to come up with cost-cutting ideas to save the overspent trust£10m. In a statement the trust said that in light of the plan to achieve foundation trust status, ‘there now needs to be a commitment over the next five years to drive further changes’.
‘Unacceptable examples’: the failings
The Healthcare Commission report details a catalogue of failings in the trust’s handling of C difficile.
There was no recognition in the trust or local health community of its relatively high rate of infection over several years. A doubling of background levels of infected patients in autumn 2005 (the first outbreak affecting 150 patients) was not identified. Only with a second outbreak in spring 2006 were the strategic health authority and Health Protection Unit involved.
Trust policy for responding to outbreaks ‘was not fit for purpose’. Some infected patients were nursed on open wards and other patients caught C difficile.
It took four months to set up an isolation ward for patients with C difficile - partly because of pressure on beds and a desire to meet targets.
Patients and families complained about the standard of care and the lack of dignity. Patients with diarrhoea were sometimes told to ‘go in the bed’.
Wards, bathrooms and commodes were not clean. Shared equipment was not cleaned between patients. In April 2007 the commission found ‘unacceptable examples’ of contaminated equipment.
The then director of infection prevention and control - who was also the director of nursing and patient services - ‘had no real understanding of his role at the outset’, and in the 2005 outbreak ‘failed in his duty to ensure adequate surveillance systems were in place’. He still works for the trust in a different capacity.
The 2006 outbreak was not discussed in public for three months and then inaccurate information was given.
‘The trust’s board was dominated by finance, targets, the PFI and reconfiguration.’
The trust’s board paid ‘insufficient attention to its responsibilities to protect patients against infection’, despite ‘repeated reports indicating poor care on the general wards’.
And the recommendations
Beside recommendations for the trust, the report makes points which apply across the NHS.
The diagnosis of C difficile should be a diagnosis in its own right.
Commissioners should ensure that trusts have appropriate guidelines for C difficile prevention and management.
Recording of C difficile on death certificates needs to improve.
Boards must understand the role of the director of infection prevention and control and receive information on incidence and trends in healthcare-associated infections.
The NHS and the Health Protection Agency need to agree arrangements for monitoring C difficile.