Pseudomonas outbreak one year on: police begin investigation into babies' deaths

By Niall McCracken

THE PSNI’s Serious Crime Branch is conducting “preliminary investigations” into the circumstances surrounding the death of four babies from pseudomonas at two Northern Ireland hospitals, 12 months after the tragedies occurred.

This week marks a year since the death of the third and last baby to die as a result of the outbreak at the Royal Jubilee Maternity Hospital in Belfast. Another baby died almost six weeks earlier after contracting pseudomonas at Altnagelvin Hospital’s neonatal unit in Derry.

Speaking to The Detail, the solicitor representing the family of “Baby 3” says while they welcome news of an investigation, the anniversary of their baby’s death is harder to come to terms with because many questions remain unanswered, with no one yet held to account.

On January 3 2012 a baby died of the pseudomonas infection, contracted while undergoing treatment at the Royal Jubilee Maternity Hospital’s neo natal unit. By January 6 2012 a second baby had died in the same unit of the RJMH from pseudomonas infection. A month previous on December 10 2011, a ten-day old prematurely-born baby who had become infected with another strain of Pseudomonas had died at Altnagelvin hospital.

On January 11 2012 “Baby 3” was born prematurely at the Royal Jubilee Maternity Hospital and transferred to the neonatal unit. Five days later “Baby 3” was put on antibiotics and the baby’s family were informed that their baby was “very sick”. By January 19 2012 an outbreak of pseudomonas was declared at RJMH, later that evening “Baby 3” died as a result of the infection.

Belfast solicitor Ernie Waterworth, who represents the family of “Baby 3”, has asked the police to look into allegations of corporate manslaughter against the Belfast Trust.

A spokesperson for the PSNI said it was conducting preliminary investigations into the circumstances surrounding the deaths of four babies from pseudomonas at two Northern Ireland hospitals in December 2011 and January 2012. It confirmed that two families had made complaints to police but the families of all four babies had been made aware of the situation.

At the end of January 2012 the Health Minister Edwin Poots asked the Regulation Quality and Improvement Authority (RQIA) to undertake a review of the circumstances contributing to the occurrences of pseudomonas infection and colonisation within neonatal units in Northern Ireland.

A year on, Mr Waterworth of McCartan Turkington & Breen law firm, says the family of “Baby 3” need answers and accountability.

He said “When the final report of the independent review was published, the family were very disheartened; they were given guarantees that specific concerns would be addressed. This wasn’t the case and they found it very patronising in parts.”

As previously reported by The Detail the father of baby 3 had raised specific questions about gaps in hospital records that failed to make note of cuts present on their baby’s skin, just days before their baby died.

The final report was published at the end of May, but contained no reference to the family’s concerns, even thought they had specifically raised it with the review team, the Belfast trust and the Health Minister ahead of publication.

The Corporate Manslaughter and Corporate Homicide Act (2007) came into force in on April 6 2008.

The legislation states: “Juries will consider how the fatal activity was managed or organised throughout the organisation, including any systems and processes for managing safety and how these were operated in practice”.

While there has only been one successful conviction to date in Northern Ireland under the Corporate Manslaughter and Corporate Homicide Act (2007) – and not within a medical setting, Mr Waterworth says his clients have a very strong case.

He said “Basic questions like why the hospital was not using sterilised water on the ward as had been the practice before remain unclear. Each of the pseudomonas deaths are tragic and all the families deserve answers. The fact that my clients’ baby was the last to die is also hugely significant and how the systems in place failed after three babies had already died needs to be addressed.

“The family were informed late last year that there wasn’t going to be an inquest into their baby’s death so a police investigation underpinned by corporate manslaughter legislation really is the last avenue by which they can get the answers they deserve.”

REGULATION

In 2008, following the outbreak of other C Diff cases in the Northern Trust area, the RQIA was tasked with conducting infection prevention/hygiene inspections at hospitals across Northern Ireland. In a previous story from February last year, The Detail revealed that the regulator had never inspected any of Northern Ireland’s neonatal units before the outbreak.

However, a spokesperson for the regulator said that following the outbreaks of pseudomonas, it had developed a range of specialised audit tools for Augmented Care areas and had visited various locations to test and evaluate the audit tool:

“The final set of audit tools will be published shortly. This will form the basis for RQIA’s programme of infection prevention/hygiene inspections at augmented care settings, including neonatal units, in the year ahead.”

On December 12 2011 the Western Trust declared an outbreak of Pseudomonas at the neonatal unit at Altnagelvin Hospital, after three babies were confirmed to be infected. One baby had died and a second baby had been transferred to the regional neonatal unit in the Royal Jubilee Maternity Service (RJMS). The third baby continued to be cared for in Altnagelvin at that time.

As previously reported, hygiene audits obtained by The Detail under FOI revealed that significant hygiene failures in Altnagelvin’s neonatal unit went unresolved for weeks and sometimes months in the lead up to the pseudomonas outbreak.

We asked the Western Trust to provide us with its Environmental Cleanliness Audits and Hand Hygiene Audits for Altnagelvin’s Neonatal Ward from June 2012 to December 2012.

The data shows that the hygiene scores are consistently compliant scoring over 90 on a regular basis. The Environmental Cleanliness audits took place on a weekly basis until the start of October 2012 when the trust adopted RQIA’s Environmental Cleanliness audit tool which it says is a “much more robust tool” and moved to fortnightly audits.

A spokesperson from the Western Trust added: “The Western Trust’s Neonatal Intensive Care Unit (NICU) at Altnagelvin Hospital consistently performs well in environmental cleanliness and hand hygiene audits and this is demonstrated in the results that have been shared for the period June 2012 to December 2012.

“Clean health care facilities are essential for public confidence and as such are recognised as being integral to the delivery of high quality services and linked to the prevention and control of infection. Patients and the public expect wards and departments to be clean and to be kept clean. The Trust ensures that all staff play their part in achieving clean facilities”.

On January 19 2012 the Belfast trust publicly declared an outbreak of Pseudomonas in the RJMS regional neonatal unit. At that time two babies who had been confirmed as having the infection had died and a third baby died on the evening of the announcement.

Updated results for RJMS Neonatal Unit’s hygiene audits also show improved standards with most of the results scoring at over 90%. The Belfast Trust said that the only week that had a score of 81% was due to the audit being carried out in the area immediately after refurbishment before a deep clean had been carried out.

Please click here to view the full hygiene results.

Previous hygiene results obtained by The Detail for RJMH’s neo-natal ward last year had highlighted concerning risks around the unit’s sink areas.

Sink taps had previously emerged as the source of the infection and in previous coverage by The Detail following the outbreak, had shown that a sink “needed cleaned” and was failing in one of the neo natal’s Intensive Care Unit’s bedded areas, on the day of the first baby’s death.

Commenting on the latest environmental cleanliness audits a spokesperson for the trust said the Royal Jubilee Maternity Hospital consistently performs well in all environmental cleanliness and hand hygiene audits.

“Staff in the Neonatal Unit (NNU) continue to carry out unannounced hand hygiene audits and any deviation from the seven step technique is immediately addressed. The NNU works closely as a multidisciplinary team addressing infection prevention and control issues through the Clearing Serious Infection Forum which includes staff from the Infection Prevention and Control Nursing Team.”