By
Royal Victoria Hospital
The pseudomonas outbreak claimed the lives of four premature babies in December and January and a central function of the Troop review into the outbreak is to set down measures to ensure it never happens again.
We now know that since 2008 26 other people who died in Northern Ireland had “pseudomonas infection” on their death certificate but that none of these deaths was treated as a serious adverse incident; nor did any result in a coroner’s inquest.
Oversight of hygiene in the high-risk neonatal unit was either ineffective – as the internal hygiene audits highlighted by The Detail last month have revealed; or non-existent – we have also established that to this day there has NEVER been an inspection by the external oversight agency, the Regulation and Quality Improvement Authority, which is now facilitating the review of this tragedy.
It was against this background that “Baby 3” was born and died at the Royal Jubilee Maternity Hospital in January 2012.
This timeline sets down the experiences of “Baby 3”’s family within the context of the wider picture of healthcare infection and infection control in Northern Ireland.
May 2009: The parents of “Baby 3” first child is born prematurely in the Royal Jubilee Maternity ward’s neonatal intensive care unit. They say that sterile water is used for everything including washing and bathing and that this practice is clearly an established protocol in the unit.
15 September 2010: Department of Health issues circulars and advices to staff in respect of water sources and potential infection risk to patients to raise awareness of potential cross-infection risks from taps and basins. This followed receipt of a number of reports from English NHS Trusts concerning outbreaks of infection with Pseudomonas. The lesson from England was to monitor the water delivery systems in healthcare facilities to minimise and manage the risk of contamination by organisms such as legionella and pseudomonas
1 July 2011: Letter by the Health Estates Investment Group circulated to chief executives of all health trusts, the Health and Social Care Board and Public Health Agency as well as the oversight agency, the Regulation and Quality Improvement Authority. It points to an awareness of the issues surrounding such bacterial infections as pseudomonas.
4 November 2011: Internal hygiene inspection in Royal Jubilee Maternity Hospital( RJMH) neonatal unit – notes that the sink in the bedded area of the neonatal Intensive Care Unit “needed cleaned” and subsequently failed the inspection. Out of a possible score of 1.0 it gained 0.0.
25 November 2011: In another hygiene inspection, RJMH neonatal units sinks are once again a source of concern: it is noted that the “overflow needed cleaned” in sinks in the store of the Special Care Unit.
6 December 2011: The first case of infection relating to pseudomonas in Belfast Trust over this period is confirmed (no confirmation of location).
10 December 2011: Caolan Campbell, a ten-day old prematurely-born baby who had become infected at Altnagelvin hospital, dies.
12 December 2011: The Western Trust becomes aware of infection in its neonatal unit in Altnagelvin Hospital.
13 December 2011: The trust identified pseudomonas in a single tap within the unit. The room is closed to new admissions and the tap dismantled, disinfected and retested. The retests indicate that the tap is free from pseudomonas.
13 December 2011: Health Minister Edwin Poots is made aware of the Pseudomonas outbreak at Altnagelvin Hospital. During a committee meeting on 15 February, the Chief Medical Officer Michael McBride says the Department was advised of an awareness of a problem in Altnagelvin Hospital on 13 December, when the “trust became aware that it had three babies with pseudomonas infection at that time”.
14 December 2011: Doctors call out to the house of the parents of Caolon Campbell he had died as a result of pseudomonas infection. An outbreak control team has been convened by the trust with the Public Health Agency involved.
22 December 2011: A letter is circulated to all Northern Ireland’s health trusts warning of the danger of pseudomonas infections from taps and basins after the outbreak at Altnagelvin hospital. It reinforces previous advice issued in September 2010 and in July 2011. It makes no mention, however, of the death of the baby from the infection eight days earlier.
30 December 2011: Another hygiene audit notes sink failures twice at RJMH neonatal unit, both because of a ”build up” within sinks in the unit’s bedded areas. This is just seven days before the first death at RJMH.
3 January 2012: A baby dies of pseudomonas infection, contracted while undergoing treatment at the RJMH.
6 January 2012: Hygiene audit fails the sinks in the bedded area of room 1013 of the intensive care unit because it “needs cleaned”.
6 January 2012: A second baby dies in the RJMH from pseudomonas infection.
11 January 2012: “Baby 3” is born prematurely at the RJMH and transferred to the neonatal unit. On advice of staff, Baby 3 is washed with hot water from neonatal wards taps throughout his time on the ward.
16 January 2012: Microbiology results confirm that the two babies who died in January had died after being infected with the same strain of pseudomonas in the same unit.
16 January 2012: “Baby 3” is put on antibiotics on this day and his family are informed that “Baby 3”’s is “very sick”.
17 January 2012: The Trust meets to discuss the results of the tests on the two babies who died.
18 January 2012: Nurses hand the parents of “Baby 3” a leaflet about pseudomonas.
19 January 2012: An outbreak of pseudomonas infection is declared at RJMH.
19 January 2012: Later that evening “Baby 3” dies as a result of pseudomonas infection.
21 Janaury 2012: The Health Minister states that the use of sterile water for nappy changes is being rolled out at all HSC Trusts following a teleconference on this day, but says that the practice had been established in Londonderry and Belfast before that date.
23 January 2012: Hygiene audits of RJMH neonatal unit show that the sinks in the bedded areas of the neo-natal ward are still failing – this time because “labels needed removed”.
24 January 2012: Health Minister Edwin Poots tells the NI Assembly that the pseudomonas bacteria had been traced to taps at the neo-natal unit in the Royal Jubilee Maternity Hospital.
28 January 2012: Department issues further guidance that advises on a number of immediate steps to deal with the emerging situation: first, to protect babies. At this time, the measures involve separating babies from water, essentially, so that babies in those units are not exposed to tap water, directly or indirectly. They also put in train a range of precautionary additional actions, such as water testing, tap replacement and ongoing water testing.
31 January 2012: Minister announces “an independent review” in a statement to the Assembly.
9 February 2012: Department issues additional guidance on the water-testing schedule, specifically with regard to other augmented care units outside of neonatal intensive care — adult and paediatric critical care areas. This is due to be published late March 2012.
20 February 2012: RQIA announces Pseudomonas Review Terms of Reference and Independent Review Team Membership.
7 March 2011: Health Committee Chair Sue Ramsey claims that the members of committee should have been informed about the hygiene reports instead of having to read about them in the media.
15 March 2012: George Robinson MLA tables a number of RQIA and hygiene audit centric questions to the Health Minister.
4 April 2012: Health committee is presented with an interim report of the review.