In a statement to the Assembly, the Minister said that having received the final report from the Regulation and Quality Improvement Authority (RQIA), a number of questions still remained unanswered.
He said: “It is clear from both this final report and the RQIA’s interim report published in June, that infection prevention and control were high on Trusts agendas’ and that Clostridium difficile was taken seriously as an issue across Northern Ireland.
“There are some 17 recommendations in the review and we will now get on with the work of implementing them. However, two important issues remain unanswered; firstly, how many people died as a result of the outbreak and, secondly what were the experiences of patients and others who were directly affected by the outbreak?
“I want to restore public confidence in the safety and quality of healthcare. That is why I have decided to hold a public inquiry that will examine these questions. I will advise the Assembly in due course of the Terms of Reference and the membership of the inquiry team.”
Turning to the report’s findings on infection control practices the Minister said that the Northern Trust appeared to be as well prepared as any other Trust in Northern Ireland to deal with an outbreak.
He said: “However, the review also found that the Trust did not have good systems in place to ensure that policies adopted by the Trust Board were being implemented and observed at ward level. For example, an antibiotic policy was in place but there were problems with adherence to it.
“The report also points to issues with infection control systems and cleaning arrangements in the Northern Trust, significant level of patient transfers between hospitals and shortfalls in nursing and cleaning staff in the parts of the Trust.”
“Once the outbreak was declared the Chief Executive immediately took personal control. An Outbreak Control Team was convened which the review team found helped to speed up decision-making.”
Practical and financial support to the Trust was provided by the Northern Health and Social Services Board to manage the outbreak, and officials in the Department provided support to the Trust when the outbreak was declared.
The NHS Cleaner Hospitals Team also helped to support the Trust and the outbreak was declared over in August.
Mr McGimpsey said: “I want to take this opportunity to pay tribute to the staff in the Northern Trust who worked extremely hard over a long difficult period to bring this outbreak under control.
“The RQIA review team have identified a number of valuable lessons which can be applied not only in Northern Ireland but further afield. Our clear duty is to act on these lessons, to do that across Northern Ireland, and to do it without delay.”
Notes to Editors:
1.A copy of the RQIA report is available on the department’s website at: http://www.dhsspsni.gov.uk/assemblydocumentcdiff14108.pdf
2.The Minister’s statement to the Assembly is available at: http://www.dhsspsni.gov.uk/assemblystatementcdiff14108.pdf
3.The review team’s interim report was published on 3 June 2007.
4.Based on information provided by the Registrar General on data up to 31 May 2008, C. difficile was mentioned on the death certificates of 41 of these 297 patients.
5.The principle conclusion of the review is that the outbreak was caused by the emergence of the virulent 027 strain in Northern Ireland, and that a lack of awareness of the implications of 027 led to some delays in decision-making.
6.There are 17 recommendations in the final report, in addition to 36 recommendations that were made in the interim report. They are:
- the establishment of a formal risk assessment system for emerging threats from specific infectious diseases, to be led by the new Regional Agency;
- a review of regional arrangements for public health advice and outbreak support for Trusts;
- further action on antibiotic prescribing, led by the new Antimicrobial Resistance Action Committee;
- robust infection surveillance system including regular monitoring of virulent strains, at regional and Trust levels, and
- a review of arrangements for ensuring implementation of key regional policies and compliance at patient level.
- a review of the current system for reporting Serious Adverse Incidents, and new guidance on roles and responsibilities in relation to healthcare-associated infections;
- a review of undergraduate education and Continuous Professional Development requirements for clinical staff in respect of infection control and antimicrobial prescribing, and
- a baseline review of all Trust cleaning arrangements against current standards and methodologies.
- effective arrangements for monitoring the implementation of policies at ward level;
- arrangements for HCAI surveillance within Trusts;
- development of escalation plans for dealing with virulent strains;
- daily assessment of each patient with C. diff;
- assessment of risk factors for every new patient with C. difficile infection and regular reviews of the results;
- a de-cluttering review of ward environments
- timely and complete information for patients during their stay, which meets the needs of patients, carers and families, and
- the establishment of a system to ensure that patients’ views of their experiences are used to inform the delivery of services.
- the Northern Trust should put in place a comprehensive communication strategy to ensure the whole workforce is fully briefed and everyone understands their own responsibilities with regard to the quality and safety of patient care.
- There is one further phase to the RQIA review, which is an examination of the implementation of the Changing the Culture strategy. That phase of the review has now started.
8.Media queries to Clare Baxter, DHSSPS Press Office on 07919 400248 or 02890 520636 or out of hours contact the Duty Press Officer via pager number 076 9971 5440 and your call will be returned.
