Between April 2004 and September 2006 more than 1,170 patients were infected across the Maidstone and Tunbridge Wells NHS Trust’s three hospitals in Kent.
The Healthcare Commission estimates that about 90 of these patients definitely or probably died as a result of the infection. 60 of these deaths occurred in two major outbreaks.
The first of the two outbreaks occurred between October and December 2005, affecting 150 patients. Despite the fact that the monthly number of new patients with C. difficile doubled, the trust failed to identify the outbreak at the time. A further 258 patients contracted C. difficile in a second outbreak from April to September 2006.
The Commission found that the trust had not put in place appropriate measures to manage and prevent infection, despite having high rates of C.difficile over several years.
The Commission found that the trust board was unaware of the high infection rates and did not spend enough time considering issues relating to infection control.
The board also did not address problems that were consistently raised by patients and staff. These included the shortage of nurses, poor care for patients and poor processes for managing the movement of patients from one ward to another, all of which contributed to the risk of spreading the infection.
Evidence from patients, staff and the trust’s own records show that patients, including those with C. difficile, were often moved between several different wards, increasing the risk of spreading infection. In some instances this was due to concern about meeting the government’s target for waiting times for treatment in A&E wards.Healthcare Commission report
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