Fatal Clostridium difficile outbreaks in hospitals throughout UK - hundreds dead but remarkably, no-one is responsible

Probably one of the worst examples of hospital acquired infections was reported Thursday, October 11, 2007 Rose Gibb resigns - Kent & Sussex Clostridium epidemic kills patients - all targets met.

A report from health watchdog, the Healthcare Commission, concluded that infection by Clostridium difficile probably or definitely killed at least 90 patients and was a factor in the deaths of a further 241 in 3 Hospitals (Maidstone Hospital, Kent and Sussex Hospital, Pembury Hospital) run by the Maidstone and Tunbridge Wells NHS Hospital Trust . Kent Police and the Health and Safety Executive were to examine the report to cosider if there was a case for criminal prosecution. BBC Full report 128 pages

Now Kent Police and the HSE have concluded their review . This consisted, it appears, of series of interviews with the Commission's lead investigators and all the experts who considered the information gathered by the Healthcare Commission in compiling their report. HSE has concluded that whilst mistakes had been made, there is insufficient information to launch a criminal investigation.

It must be remebered that the Healthcare Commission report stated .."Due to poor documentation and record keeping by the trust, a lack of agreed methods and staff being unable to recollect events, the Healthcare Commission has been unable to clarify the precise nature, timing and findings of the various case note reviews undertaken by the trust. "

Which must gladded the hearts of the relatives of 331 people who died in the massive outbreak which was reported immediately prior to the premature departure of CEO Rose Gibb. This highly unpopular , but highly paid lady (her salary was reportedly £150K pa plus 12.5 K pension contribution and her £250 K payoff is still subject of litigation) was responsible for the hugely unpopular "reconfiguration "plans for the two hospitals which saw the down grading of Maidstone Hospital A&E services. Her plans had also included the loss of children’s and maternity services.

Sandra Caldwell CB, HSE Deputy Chief Executive, is reported saying that she has expressed her sympathy to all those affected.

She also makes the astonishing conclusion that ," from the information available, we cannot establish with certainty a causal link between failings to manage infection and the death of any particular person. "

"The Trust has acknowledged that mistakes were made and their senior management team has changed substantially."

So that's alright then.

See previous posts on this case here

However this is a repeat performance by our Sandra (since promoted it seems) - some may remember this on Tuesday, November 20, 2007

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.

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.”