- Inspectors warned of “high” risk to patient safety
- Trust plans to move facilities to new building by the end of the year
- Oncology aseptic unit now safe, trust says
Legionella and pseudomonas were found in water meant for hand washing in a unit where medicines for cancer patients were prepared, HSJ has learned.
The facilities at Maidstone and Tunbridge Wells Trust’s Maidstone Hospital were found to pose a “high” risk to patient safety in an inspection by NHS’ Specialist Pharmacy Services.
The inspection — details of which were released to HSJ under the Freedom of Information Act — revealed problems in both the hospital’s oncology aseptic unit and its aseptic unit in the main pharmacy. These included:
- Monitoring of hand washing water had been stopped by the estates department without the knowledge of the pharmacy department. The legionella and pseudomonas were isolated once it was reinstated;
- Both units were poorly designed and their physical condition deteriorating. The pharmacy facilities had holes in the ceiling of one of the rooms and the air handling unit in the oncology unit frequently broke down, leading to temporary closures;
- The oncology unit’s design compromised process control. Multiple trays were placed in isolator hatches (where drugs are prepared) when there should only have been one; and
- Numerous documents were past their review date.
The inspection report raised the overall level of risk to patient safety from “significant” to “high”, and warned the pharmacy aseptic unit should not be used as back up for the oncology unit until essential repairs were carried out.
Units inspected by the SPS are given an overall risk assessment for patient safety of “high”, “significant” or “low”. In addition, individual areas are ranked “critical”, “major”, “other” (which is minor or moderate) or “satisfactory”.
The inspection at Maidstone, in July, also led to three areas being rated as having major deficiencies: facilities and equipment; pharmaceutical quality systems; and aseptic processing. Within these areas, there were six major deficiencies. Other areas had moderate or minor issues identified and only one area — prescribing, clinical pharmacy and aseptic services verification — was assessed as satisfactory.
MTW plans to move all aseptic work to a new purpose-built unit at its Tunbridge Wells Hospital by the end of 2020, but the inspection report warned “careful management of the facilities will be needed over the interim period to manage the risks”.
The trust said SPS was monitoring the Maidstone facilities regularly to ensure safety remained at a level which would keep them operational. The most recent inspection was late last month and found the units were safe to operate, it said.
A trust spokeswoman said MTW had put in place a number of actions and addressed the issues raised in the time requested. Actions included carrying out repairs, reinstating the hand washing unit monitoring schedule, improving administration systems and handling processes, and holding weekly inspections of the facilities to spot signs of deterioration.
They continued: “MTW is collaborating with the Kent and Medway [Sustainability and Transformation Partnership] to deliver a new model of aseptic services that is sustainable and fit for the future. We would like to reassure our patients that our aseptic service is safe and that no patient is at risk.”
They added the trust was sure the service’s rating would “significantly improve once the new unit in modern facilities opens later this year”.
Updated to correct typo at 13:15 on 11 February
Information obtained by HSJ; Trust statement
July 2019; February 2020