Stoke Mandeville Hospital escapes HSE prosecution after Clostridium outbreak kills 33 people

Stoke Mandeville Hospital was investigated by the HSE after a Healthcare Commission (HC) report claimed that there were “serious failings” in the hospital’s response to Clostridium difficle infection infecting 334 and killing 33 patients between October 2003 and June 2005. The HSE decided that they were unable to bring criminal proceedings against the trust due to a lack of “admissable evidence”.

Thames Valley Police and the Crown Prosecution Service were asked to consider the HC’s report under the terms of the “Work-Related Deaths Protocol”. Their conclusion was there was insufficient evidence of a “causal link” to the action of any individual and the deaths of the patients involved.

Individual victims, or thier families may of course prosecute in particular cases where they believe clinical negligence may have occurred.

Sandra Caldwell, HSE Director of Field Operations, said:

“On the basis of the evidence available, HSE did not find sufficient admissible evidence to be able to bring criminal proceedings against the Trust, alleging a link between management failures and particular deaths.”

“We did find some breaches relating to the requirements to keep documents. However, as these were not directly linked to any of the deaths and were of a relatively minor nature, HSE decided that it would not be in the public interest to bring legal proceedings against the Trust and its managers in relation to these matters."

An investigation into the handling of C. difficile outbreaks at Maidstone and Tunbridge Wells NHS Trust in which 90 people died is still being carried out by the HSE and Kent Police.
The Healthcare Commission report July 24th 2006 ..

"The primary factor however, was the failure to isolate patients with the infection. The nature of the hospital made control of the infection extremely difficult. There were few single rooms that could be used to isolate patients with infections and, in 2003, the number of rooms available for isolation was cut further because of the Trust’s decision to reconfigure its wards and ring fence beds to prioritise other patients.

The Trust’s drive to meet the target for A&E, which requires all patients have a maximum wait of four hours from admission to discharge, led to some patients with infections being admitted or moved out of A&E within the target time into open wards rather than isolation facilities. "

Complete HC report on the outbreaks at Stoke Mandeville here as pdf

C. Difficile Support group website

See also previous post hereThursday, October 11, 2007 Rose Gibb resigns - Kent & Sussex Clostridium epidemic kills patients - all targets met.

Also see all Clostridium posts here