Exclusive: 11 patients infected in ‘unsafe’ endoscopy unit

The potential hazards posed by ageing equipment and an “outdated” environment at the unit had been identified on Worcestershire Acute Hospitals Trust’s risk registers for “a number of years”.

The trust said in an internal report that it had not been able to address the situation because of delays to its controversial plans to reconfigure acute services across Worcestershire.

According to the report, obtained by HSJ via a Freedom of Information request, problems began in March when bacterial growth was detected in the decontamination facilities of Alexandra Hospital’s endoscopy unit.

The report said the appearance of the bacteria coincided with “two probable cross-infection incidents” among patients undergoing endobronchial biopsy with ultrasound guidance – a procedure that allows doctors to look into the lungs.

In the first incident “samples from seven patients out of 13” grew Pseudomonas, a germ which can cause respiratory and chest infections in some patients.

The second incident occurred from mid-June until early July, when a different bug, Serratia, was isolated from four patients.

When asked whether the infections had resulted in patients experiencing harm, a trust spokeswoman said it could not discuss individual cases. 

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The report said the unit’s machines for decontaminating endoscopes have “been in situ for over eight years and are overdue for replacement”.

The environment of the unit was described as “outdated”, “unsafe” and “unacceptable”. The decontamination area did not allow for good separation between “clean” and “dirty” instruments, the document said.

The report continued: “The environmental issues including the age of the equipment have been on the directorate and divisional risk registers for a number of years.”

Plans were in place to revamp the endoscopy unit with the redevelopment of the Alexandra Hospital theatres as part of a wider reconfiguration of services across the trust.

However, delays to the controversial reconfiguration have prevented action from being taken.

The spokeswoman said that on the advice of the consultant microbiologist, decontamination of certain scopes was temporarily suspended at the unit while the equipment supplier installed pre-filters to improve the quality of water entering the machines. She said that the suspension was lifted following the installation and no further incidents had occurred.

She added that procurement for three new decontamination machines would be “complete imminently”.

“Preliminary plans have been drawn up for the service reconfiguration of endoscopy services, however this will not be a standalone solution,” she said.

“They must align to the wider service reconfiguration across all three sites and all services to ensure that [the trust] provides the best possible care and experience for our patients.”