Sixty died at hospital after patients left in human filth
By Sam Lister, Health Correspondent and Jenny Percival
More than 60 people died at a single hospital from complications linked to the superbug Clostridium difficile as a result of serious failings of senior management, a highly critical report said today.
Two outbreaks at Stoke Mandeville Hospital, in Buckinghamshire, killed more than 33 people, while a culture of poor hygiene and hospital managers’ failure to act contributed to several dozen additional deaths since 2003, the health inspectorate said.
The report — which detailed a catalogue of serious hygiene offences including faeces on bed rails and patients’ clothes kept on the floor — was published as annual figures revealed that rates of C. difficile in patients over the age of 65 have risen across England by 17.2 per cent in the last year.
The second report, by the Health Protection Agency, showed that the number of cases of C. difficile rose in two-thirds of health trusts, despite government efforts to improve hospital hygiene.
The HPA statistics showed there were 51,690 cases in 2005 up from 44,107 in 2004. The cases relate to infections in patients aged 65 years and older. The HPA said the increase was likely to be down to both an increased number of cases and improved reporting.
Patients and relatives of those that died at Stoke Mandeville are expected to pursue legal action after the Healthcare Commission’s damning findings on the management of Buckinghamshire Hospitals NHS Trust.
Describing the situation at Stoke Mandeville as a result of repeated failures by the trust’s board, Anna Walker, chief executive of the Healthcare Commission, said that government targets, the control of finances and the reconfiguration of services had been put above basic patient care.
"The leadership of the trust compromised the safety of patients by failing to make the right decisions," she said, adding that they had failed to learn lessons from the first outbreak, which killed 16 people. "They rejected the proper advice of their own experts."
The Healthcare Commission, an NHS watchdog, said that more than 300 patients contracted the C. difficile stomach bug at the hospital in the outbreaks between October 2003 and June 2005. The bug causes severe diarrhoea and can be fatal, particularly for elderly patients.
The commission blamed the spread of the bug on the failure to isolate infected patients. Hospital managers reduced the number of single rooms, which could have been used to keep those infected away from other patients.
A shortage of nurses contributed to an environment where staff were too rushed to answer call bells or change soiled sheets and failed to take basic precautions such as washing their hands, wearing aprons and gloves or properly cleaning mattresses and equipment.
Nurses at the hospital complained to the trust's chief executive and to the Royal College of Nursing that they were worried about the standard of care.
Some limited action but not the most important - immediate isolation - was taken after the first outbreak but senior managers failed to bring the second outbreak in 2005 under control because they prioritised other objectives, like the Government's targets on accident and emergency waiting times.
The commission also revealed that an inspection at the hospital between December 2005 and January this year showed there were still problems including dirty wards and toilets and mould and cobwebs in the showers.
Andy Burnham, the Health Minister, said that its medical advisers would study the report’s recommendations. "What happened at Stoke Mandeville is inexcusable and must not be allowed to happen again," he said.
Alan Bedford, Buckinghamshire Hospitals NHS Trust acting Chief Executive, who replaced the former head Ruth Harrison, said the hospital had since tightened its procedures. "We are determined to learn everything we can from the report," he said. "The death of any patient from a hospital-acquired infection is a cause of deep concern and regret."
Three senior managers at the trust have left or have announced their plans to leave this month and the hospital announced today that a new post with sole responsibility for infections control will be created.
The latest figures from the Health Protection Agency also revealed that the number of reported cases of MRSA blood poisoning had dipped by 2.5 per cent to 3,517 between October 2005 and March 2006 compared with the previous six months.