Explosive report: 'Pseudomonas babies could have been saved'

Poor communication and the use of contaminated water in nappy changes revealed in scathing report

An interim report into the Pseudomonas outbreaks in Northern Ireland has made 15 recommendations for improvements after finding a lack of communication between trusts

An ‘explosive report’ has suggested that the lives of four babies who died from Pseudomonas infection at neonatal units in Northern Ireland could have been saved if trusts had communicated better and implemented control measures more quickly.

An interim report into the causes and impact of the outbreak, ordered by Health Minister, Edwin Poots, raises serious questions about the response to the tragedy and lays down 15 recommendations for urgent improvements.

To date we have visited every neonatal unit to examine the causes of the outbreaks of infection and we have considered the responses of those organisations involved in dealing with the situation

The independent review was led by Professor Pat Troop and suggests that at least some of the infants could have survived if Belfast Health and Social Care Trust had taken action more quickly following the first reported case at the Royal Jubilee Maternity Hospital in January. Instead, the report claims that staff continued to use contaminated tap water during nappy changes, a measure thought to be the main cause of transmission to to the infants.

It also criticises the reporting system for declaring and dealing with an outbreak after the first fatality at Altnagelvin Hospital in December. Professor Troop said that, although a circular was sent by the Chief Medical officer, Dr Michael McBride, to all trusts following the death, it did not specifically mention Pseudomonas , merely urging infection control teams to assess risk at all units.

Discussing her findings with the Stormont Health Committee, Professor Troop said that, while the Western Health and Social Care Trust appeared to have taken some control measures after the first baby died at Altnagelvin, she was ‘far from satisfied’ with the way Belfast Health and Social Care Trust had dealt with its outbreak, claiming action was only taken when ‘quite a number of babies were infected’.

And she said that, if the trust’s response had been quicker, it was ‘possible’ that lives could have been saved.

"When the unit thought that they may have an outbreak, they stepped up their infection control but they did not test the water and they did not introduce sterile water for cleaning the babies," she said.

“Had they done that, it might have improved the situation somewhat earlier."

Promising to continue the probe, Poots promised there would be ‘no cover-up or sham’, adding that he intended to implement the 15 recommendations laid out in the report immediately.

The results of the investigation were published by the Regulation and Quality Improvement Authority, an independent body responsible for regulating and inspecting the quality and availability of health and social care services in Northern Ireland. Sue Ramsey, chairman of the Stormont Health Committee described the findings as ‘quite explosive’ and said families of the babies that died needed to know exactly what happened.

When the unit thought that they may have an outbreak, they stepped up their infection control but they did not test the water and they did not introduce sterile water for cleaning the babies. Had they done that, it might have improved the situation somewhat earlier.

The report highlighted that all five neonatal units in Northern Ireland said it was normal practice to use tap water for nappy changes, as is the case in many similar facilities elsewhere in the UK. The review team believe this water was a likely route of transmission of Pseudomonas from the taps to the babies. At the Royal Jubilee Maternity Hospital it was also revealed that tepid tap water was used to defrost breast milk and this could also be responsible for the infection getting into babies’ systems.

Professor Troop said: “To date we have visited every neonatal unit to examine the causes of the outbreaks of infection and we have considered the responses of those organisations involved in dealing with the situation.

“The review team has concluded that the outbreaks were linked to contaminated tap water in the intensive care rooms of the neonatal units. We believe the most likely method of spread to babies was the use of tap water in washing during nappy changes. The review team recommends that only sterile water is used for washing babies in these units.”

She added that the outbreaks and incidents at the two hospitals, and a number of other units where the bacteria was identified or babies were found to be colonised, were caused by different strains of the bug, but said the review team was recommending a common approach to infection control and surveillance for Pseudomonas in the future.

Since the outbreak, all taps in all neonatal units across Northern Ireland have been replaced and bacterial screening and deep cleans carried out. In addition, governments in England, Northern Ireland, Scotland and Wales are drawing up formal guidance. The Department of Health in England has issued technical guidance for healthcare providers on managing, preventing and controlling outbreaks of Pseudomonas ; while the UK Advisory Committee of Antimicrobial Resistance and Healthcare Associated Infection has established a sub group to advise on the management of infection in neonatal units. In Northern Ireland, the taps removed during replacement have been sent for analysis by the Health Protection Agency laboratory at Porton Down and the Public Health Agency is already working on an epidemiological investigation of all the cases.

The family are heartened by the minister’s openness and acknowledgement that mistakes have been made; mistakes that they believe led to the death of their eight-day old baby

Belfast Health and Social Care Trust has announced it will carry out its own root cause analysis of the circumstances leading to the outbreak. Medical director, Dr Tony Stevens, said this week: “All our clinical staff are reflecting on how we handled this, and whether there was a short period of time when we could have done things differently. We accept that and we believe that if we had done things slightly differently, it might have made a difference for some, but not all, of the patients."

Specific recommendations made in the interim report, the full version of which is expected at the end of May, include the need for the ‘urgent replacement’ of the Royal Jubilee Maternity Hospital neonatal unit. The review team claimed there was not enough space around each cot to allow infection to be adequately controlled, and noted a lack appropriate accommodation for isolation or cleaning equipment.

Other demands include:

  • The current arrangements for testing water in neonatal units in Northern Ireland for Pseudomonas should be continued pending early consideration of the Department of Health (England) guidance issued on 30 March. This guidance sets out recommendations for water testing for all augmented care units including neonatal care
  • The presentation of test results of water samples should be standardised across the laboratories which undertake this for health and social care organisations
  • Guidance on cleaning sinks should be reviewed so that practice is standardised across all clinical areas
  • Regional guidance on the cleaning of incubators and other specialist equipment for neonatal care should be produced
  • Independent validation of hand hygiene audits should be carried out on a regular basis, supported by robust action plans where issues of non-compliance are identified
  • The intensive care accommodation in the neonatal unit at Antrim Area Hospital should be expanded to allow more circulation space around cots
  • Pseudomonas should be identified as an alert organism for neonatal intensive and high dependency care. When identified from a sample from a baby, taps and sinks should be tested in all rooms which have been occupied by that baby since birth
  • Surveillance arrangements should be established for augmented care settings including neonatal care
  • All relevant organisations should work to an agreed regional protocol for the declaration of outbreaks
  • Arrangements for the typing of strains of Pseudomonas should be established in Northern Ireland
  • A regional neonatal network should be formally established in Northern Ireland
  • The hours of availability for the regional transfer service for neonates should be expanded with plans put in place to move to a 24-hour service

Following the publication of the report, Ernie Waterworth of McCartan Turkington Breen Solicitors, which is representing the families of one of the babies who died at the Royal Jubilee Maternity Hospital, said: “The family are heartened by the minister’s openness and acknowledgement that mistakes have been made; mistakes that they believe led to the death of their eight-day old baby.

“While there are reassuring aspects of the report, there are still many questions that remain to be answered and it is hoped that the final report scheduled to be released at the end of May will address all the issues.

“My clients are in receipt of the hospital records relating to their baby and these show an area or areas of concern. They took the opportunity to raise these concerns with the minister and it is their expectation these matters will be fully addressed and explained.”

To read the full interim report, click here

To read the two NHS England guidance documents, click here and here

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