Hospital trust sentenced over fatal Legionnaires' disease and patient window fall
The first concerns at least seven patients being infected with legionella, the bacteria that causes Legionnaires' Disease, from the hospital's water system.Fifty-four year-old Raymond Cackett died in March 2010 as a direct result of developing Legionnaires' Disease. It also contributed to the death of 74-year-old patient James Compton in June 2007.
A further five patients were infected at the hospital between 2006 and 2010, as was a hospital visitor
The second incident involved a vulnerable 80 year-old patient falling almost five metres from an inadequately restricted window in June 2012. She suffered a broken back and ankle.
Chelmsford Crown Court heard how an investigation by the Health and Safety Executive (HSE) identified a catalogue of failures relating to both matters. In particular, the Trust failed to monitor the hot and cold water systems adequately or ensure that key parts of the system, such as the shower heads and hoses, were kept clean.
The legionella investigation was carried out between 2007 and 2010. It was initiated by an outbreak in June 2007 involving three patients and extended as a result of two further cases in December 2009 and two in 2010.
During the investigation, HSE worked alongside the Care Quality Commission to support the Trust to improve its management of the controls for legionella and to monitor progress through written guidance and enforcement action.
Basildon and Thurrock University Hospitals NHS Foundation Trust was fined £100,000 with costs of £162,000 after admitting breaching Section 3(1) of the Health and Safety at Work etc Act 1974 for the period between 28 February 2004 and 31 December 2010 in relation to the legionella cases.
Commenting on this part of the prosecution, HSE inspector Susan Matthews said:
"People being treated in hospitals are especially susceptible to infection. That is what makes these failings in legionella management all the more concerning.
"Not only did two families suffer the loss of their loved ones, six people suffered serious illness due to developing this potentially fatal form of pneumonia.
"Healthcare providers, like all organisations, have a legal duty to control the risks by properly maintaining hot and cold water systems.
"The Trust received numerous warnings from regulators, and consultants brought in to give the hospital advice and support, but these were not fully heeded.
"The Trust also failed to learn lessons from a previous prosecution after a death in 2002, despite having recognised that systems in place were not appropriate to protect the health and safety of its patients and visitors.
"This was a technically complex investigation and HSE will always consider prosecution where there are significant threats to the health of workers and the public."
Andrea Gordon, CQC's regional director of operations, added:
"What happened at Basildon and Thurrock University Hospitals NHS Foundation Trust is not acceptable and CQC has worked very closely with the HSE and other regulators, including Monitor, in relation to the Trust's performance regarding legionella.
"This work is ongoing and CQC carried out a review in April this year which looked specifically at the Trust's processes to control legionella. The review found that the Trust had robust systems in place to manage legionella at that time.
"We will continue to monitor the Trust, including further unannounced inspections, and will not hesitate to take action where we find standards have fallen short of what people should be able to expect."
No comments:
Post a Comment