HSE publishes
investigation report into outbreaks of Clostridium Difficile at
Stoke Mandeville Hospital
HEALTH AND SAFETY
EXECUTIVE News Release (E043:07) issued by The Government News
Network on 15 November 2007
The Health and
Safety Executive (HSE) is today publishing a report on its
investigation into two outbreaks of Clostridium difficile (C.
difficile) at Stoke Mandeville Hospital between 1 October 2003 and
30 June 2005. A copy of the report can be found at http://www.hse.gov.uk/healthservices/hospitalinfect/stokemandeville.htm
Launching the report 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."
"The HSE investigation did reveal a number of areas where
more should have been done. These recommendations have since been
implemented by the Trust but are included as key learning points
to ensure a robust approach to the prevention and control of C. difficile.
"Of particular concern to HSE was the fact that the Trust
did not have a contingency plan to help managers respond to any
outbreak. The consequence was that throughout the two C difficile
outbreaks, managers were constantly having to respond to events
rather than being able to implement and follow well thought out
solutions to foreseeable circumstance."
The evidence HSE obtained was reviewed against the standard laid
out in the Code for Crown Prosecutors, which requires that in
order for HSE to prosecute for alleged health and safety offences
there must be a realistic prospect of securing a conviction on any
alleged breach.
Notes to editors
1. HSE became involved in July 2006 after the Healthcare
Commission (HC) published a report into two outbreaks of
Clostridium difficile infection at the hospital, part of the
Buckinghamshire Hospitals NHS Trust. The HC reported that 334
patients were infected and 33 had died of C difficile infections
acquired within the hospital.
2. Before investigating the outbreaks, HSE inspectors checked the
Trust's (then) current level of compliance with health and
safety law in relation to infection control and whether they had
responded to the recommendations made to them by the HC. HSE found
that infection control procedures and supporting governance
arrangements were to a satisfactory standard.
3. HSE undertook an investigation to examine the extent to which
the deaths due to C difficile at Stoke Mandeville could be linked
to health and safety offences. HSE's investigation
concentrated on the extent to which the Trust and its managers
discharged their legal duties under health and safety legislation,
prior to and during the outbreaks and whether anyone should be
held to account before a criminal court. It was not the role of
the investigation to consider evidence relating to clinical
judgements about how individual patients were treated, nor whether
the NHS could have expected more of the Trust and its managers, as
these issues were considered at length in the HC report.
4. In view of the issues raised in the HC's report and the
possibility that serious criminal offences had been committed at
Stoke Mandeville hospital, HSE invited Thames Valley Police and
the Crown Prosecution Service to consider the HC report under the
terms of the Work-Related Deaths Protocol. Following meetings with
the HC and HSE, the police and CPS concluded that: the report did
not contain sufficient evidence of a causal link between the
actions of any individual and the deaths of the patients involved;
and therefore, a police-led investigation on the grounds of
possible manslaughter should not be initiated.
2. Further information on the Work Related Deaths Protocol can
be found at http://www.hse.gov.uk/enforce/enforcementguide/wrdeaths/investigation.htm
3. Further information on HSE's work with the Health
Services can be found at http://www.hse.gov.uk/healthservices/index.htm
Public enquiries
HSE's InfoLine 0845
3450055
Caerphilly Business Park, Caerphilly CF83 3GG
HSE information and news releases can be accessed on the
Internet http://www.hse.gov.uk
Ends