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Taps were identified as the source of the infection
THE family of the third baby who died after the pseudomonas outbreak at the Royal Jubilee Maternity Hospital (RJMH) in January 2012 have spoken for the first time to say they have concerns about gaps in the hospital records provided to them following the death of their child.
Their comments came after they met the Health Minister Edwin Poots on Wednesday (4th April) shortly before an interim report of the investigation into the outbreak of Pseudomonas here was published.
The report shows that premature babies were routinely being washed with warm tap water at neonatal units in Belfast and Derry; that four of the six taps from the Royal were infected with pseudomas; and that the taps in question had been recently installed, were sensor-activated and that there is evidence that these taps are more likely to harbor bugs than conventional hospital taps.
At this point the family of “Baby 3” wish to remain anonymous as they are still deeply distressed following the loss of their child who died on the 19th January 2012 in Royal Jubilee’s Maternity Neo-Natal Unit.
Speaking on their behalf, Belfast solicitor Ernie Waterworth of McCartan Turkington Breen solicitors, said: “The family are heartened by the Minister’s openness and acknowledgement that mistakes have been made in relation to the Royal Jubilee Maternity Neo-Natal Unit. 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 this morning to raise these concerns with the Minister and it is their expectation these matters will be fully addressed and explained.”
THE REPORTTheir statement comes as the team charged with carrying out an investigation into the outbreak gave evidence to the Health Committee and presented its interim report.
The review is facilitated by the Regulation Quality & Improvement Authority (RQIA) and the inspection team is headed up by Professor Pat Troop. It was commissioned by the Health Minister and is designed to look at the “outbreaks and incidents of Pseudomonas aeruginosa which occurred across Northern Ireland during December 2011 and January 2012.”
The interim report addresses the first two terms of reference:
1) To examine the cause of the infection.
2) To consider the responses of the organisations involved.
Key themes emerging from the report highlight that there was a lack of communication between staff in health trusts during the outbreak and the review also details that a nurse reported a leaking roof in the Royal Jubilee Maternity’s neonatal unit six days after a baby was diagnosed with pseudomonas.
The review team also noticed that there were variations in cleaning practices and the frequency of cleaning between units. In a previous article by The Detail, we highlighted significant hygiene failures with the taps within RJMS’s neonatal unit in the days and weeks surrounding the pseudomonas outbreak.
So far the review team have met with eight families whose infants had been colonised and infected with pseudomonas, including those who lost their babies. The full report is to be presented to the Minister by 31st May 2012.
The interim report claimed that generally families were initially positive regarding how they were treated by medical and nursing staff, but that some families felt that they had not been sufficiently informed about the seriousness of their babies’ condition.
For the family of “baby 3” many questions still remain around the use of non sterile water and what role this played in their child’s death.
KEY FINDINGSThe report outlined that the infection or colonisation of babies in each of the four neonatal units were associated with different strains of pseudomonas.
In Altnagelvin three babies became infected in early December 2011. Two had a single strain and one had a different strain.
In RJMS four babies became infected and 11 were colonised with a single strain of pseudomonas.
The report concluded that while analysis of samples for strain typing was still ongoing, in each unit there were separate outbreaks or clusters but that all five neonatal units in Northern Ireland had evidence of pseudomonas contamination in some of the water, sink or tap samples which were tested.
In Altnagelvin Hospital, each of the two strains which led to the infection of babies was found in one of the taps or sinks in the ICU room.
In RJMS, the strain which has been associated with five cases of infections and 10 colonised babies was detected in samples from four out of six taps in the main Neonatal Intensive Care Unit room and also from a tap in The Special Care Baby Unit (SCBU).
RQIA led review team
In Craigavon Area Hospital, a direct link has not been established between the strain linked to babies and strains tested through water sampling.
In Antrim Area Hospital, the strain in a colonised baby was different to those found in water samples.
The review team highlighted that the taps and sinks in in Altnagelvin neonatal unit had been in used since the unit opened in February 2009 and that RJMS and Craigavon neonatal units had been recently replaced, prior to the incidents.
A refurbishment of RJMS had taken place in August and September 2011 during which new taps and sinks had been installed.
SENSOR TAPSThe Interim Report spends a significant amount of time dealing with the use of sensor taps which do not require the operator to touch the tap.
It highlights concerns about links between sensor taps and pseudomonas infection and point out that there has been considerable debate regarding which design of tap is most likely to protect the water system from bacterial contamination.
In many healthcare settings, sensor taps have been introduced as the no-touch operation reduces the risk of spread of infection through touching tap surfaces.
However, the report points out that sensor taps have internal components which may support pseudomonas growth if they contain carbon. Also, there has been concern that low flow rates increase the risk of the growth of pseudomonas.
In the refurbishments which took place at RJMS in August 2011 the floor in ICU was replaced, wash hand basins with sensor taps were installed. The report also highlights that even as recent as the 8th February 2012 – rooms had new panels, new sinks and sensor taps with UV POU devices installed.
There have been a number of reports about electronic sensor taps becoming colonised by pseudomonas. In November 2011, a report was published from Turkey that an outbreak affecting 12 babies in a neonatal intensive care unit was probably due to contamination of electronic sensor taps.
STERILE WATERThe review team found that in the five neonatal units in Northern Ireland it was normal practice to use tap water for nappy changes. This has also been common practice in other parts of the United Kingdom. In units using tap water, a small container of tap water was taken from hand washing stations. The team considered that this was a likely route for transmission of pseudomonas from taps to babies.
They also found in the babies who developed the infection in Northern Ireland’s neonatal units, that many required invasive procedures such as putting in intravenous lines and intubation for ventilation. The report concluded that there is therefore a high risk that such procedures could lead to invasive infection when a baby was colonised or the skin contaminated with pseudomonas.
In conclusion the team state that the most likely method of spread of pseudomonas is from contaminated taps to babies in Altnagelvin and Royal Jubilee Neonatal Units was through the use of tap water for washing during nappy changes.
SERIOUS CONCERNSIn a response to a written assembly question in February 2012 the Health Minister explained that whilst the use of sterile water for nappy changes was only rolled out at all HSC Trusts after a teleconference on 21st January the practice had been established in the Western and Belfast before that date.
He said: “Before then the Western Trust and the Belfast Trust had already adopted this measure in response to the cases and pseudomonas colonisation of babies in their neonatal units.
“The region-wide approach was reiterated and clarified in a joint letter of 28 January to the trusts, PHA and HSC Board issued by the Chief Medical Officer and the Chief Estates Officer.”
The interim report makes 15 recommendations, the first of which refers to directly to the use of sterile water.
It states that as of the 30th March 2012 there was interim guidance in place from the Department of Health (England) which stated that sterile water should be used when washing all babies in neonatal care; it recommends that this should continue.
We asked the Belfast trust to confirm for us what procedures and protocols had been in place when dealing with the issue of sterile and non sterile water and in neonatal units before March 2012.
We are still awaiting a response.
However, the legal representation for the family of "Baby 3” has confirmed to The Detail that he had already raised such concerns with both the Minister and the review team ahead of the report’s publication.
Mr Waterworth said his clients still had serious concerns about the bathing of their child with non sterile water from the intensive care units taps, as well as a number of other issues highlighted during their time in the ward that remain unresolved.
INFORMAL NETWORKThe report found that Information about cases which had occurred in other trusts was not always readily available to inform critical decisions and that there is no agreed system for the surveillance of pseudomonas colonisation and infection which led to delays in sharing of information between trusts.
They say that the current Neonatal Network in Northern Ireland operates on an informal basis and they recommend that a formal network is established.
During today’s committee meeting, the review team pointed it out that it has already visited the five Neonatal Intensive Care Units (NICUs) in Northern Ireland.
We previously reported that RQIA had never inspected any of Northern Ireland’s neonatal units before January 2012. We can confirm that this is still the case.
In a statement from the Department it said: “The Minister has not asked RQIA to conduct hygiene inspections of neonatal units since January 2012. He has asked the Regulation and Quality Improvement Authority to develop an audit tool specifically for inspections of augmented care settings. These include the neonatal units. A working group has been established to take this forward.”
Today was not the first time the issue of hospital hygiene has been raised at the health committee. Following a Health Committee discussion on the issue of ‘Hygiene and Infection Control at the Royal Victoria Hospital’ on the 26th November 2009, former Chair Jim Wells said: “The committee has asked me to indicate that it proposes to keep the issue of hospital hygiene and cleanliness under close scrutiny and review it intends to return to the matter during future meetings.”
We can reveal that between 1st November 2009 and 1st January 2012 Hygiene Audits have only appeared twice on the Committee for Health, Social Services and Public Safety meeting agendas, both only a matter of weeks after the first discussion, on the 26th November 2009 and the 10th December 2009.