Ornamental rosettewas source of killer

The team empowered to investigate the incident has strongly recommended that the rosette design on the taps should be re-designed or eliminated to ensure the problem does not occur in future.

The revelations were made in the final report of the independent review team led by Professor Pat Troop who was charged with investigating the lethal outbreak which occurred before Christmas.

Professor Troop’s investigation centred on a series of Pseudomonas outbreaks across Northern Ireland including the one at Altnagelvin last winter that claimed the life of Caoimhe Campbell and Gavin Burke’s son Caolan on December 14.

The Altnagelvin outbreak was originally declared by the Western Trust on December 12 after three babies were confirmed to be infected.

“One baby had tragically 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,” the report states.

The killer outbreak in Londonderry was “definitively linked to a contaminated water tap in the intensive care rooms of the neonatal units” by the review team.

The report states that a study found the strains of Pseudomonas aeruginosa which caused the infection in babies in the hospital were also detected from internal components of the taps in the neonatal unit.

Crucially it partly blames the ornate design of the taps for hosting the bacteria: “The study has demonstrated a positive association of Pseudomonas aeruginosa with a complex design of rosette in the tap outlet.

“The review team strongly endorses the proposal that further work is carried out on the design of taps to address the problem which has been identified.”

It further concluded that the infection was most likely spread from taps to babies “through the use of tap water for washing babies during nappy changes.”

Another key conclusion reached by the review team was that whilst the Belfast Trust was aware of the outbreak in Altnagelvin it “did not have a clear understanding of the situation nor all the measure taken, when determining what actions to take after blood cultures were diagnosed as positive for pseudomonas on January 6, 2012, from a baby who had died on January 6, 2012. This lack of clarity may have impacted on the decision not to call an outbreak.”

But the review team said this was not the fault of staff at Altnagelvin, stating: “The review team has concluded that appropriate information was shared between the clinical team at Altnagelvin neonatal unit and the RJMS neonatal unit in relation to the care of the baby who was transferred between the two units.

“Appropriate information was also communicated to the parents of the baby who had been transferred so that they would be aware that there was an outbreak in Altnagelvin.”

Professor Troop carried out a full review of the effectiveness of the communication between the Department of Health, Social Services and Public Safety (DHSSPS), the Health and Social Care Board (HSCB), the Public Health Agency (PHA), and the five health and social care trusts in respect of all relevant information and communications on the pseudomonas bacterium.

Amongst her findings were that three trusts advised “they were not aware for several weeks that an outbreak of pseudomonas had taken place in the neonatal unit at Altnagelvin Hospital, indicating that there are not strong informal networks to share information.”

“Trusts also advised that they received limited information as to current issues across the United Kingdom in relation to infectious disease incidents,” the report states.

The review team concluded there was a need to establish a weekly infectious disease bulletin to share relevant information about incidents and issues both within Northern Ireland and from the rest of the UK.

It also investigated the transmission of information to Belfast Trust in relation to the outbreak in Altnagelvin to determine what information was clearly communicated to Belfast.

The review team concluded that there was not a clear picture in Belfast as to what had taken place in Altnagelvin in relation to the link to contaminated water from a tap or of the control measures which had been put in place.

Understandably the team recognised the devastating effect of the outbreak on the families affected.

“The impact on families affected was profound,” it found. “Through the experiences shared by the families, the review team concluded that there is important learning on how families are communicated with at such a difficult time for them.

“In general, families were satisfied with the standard of care provided for their babies but felt that communication, in particular the level of language and information regarding the seriousness of the pseudomonas colonisation/infection, could in some cases have been improved.

“Families felt that there was a need to use plain language when giving information to them about their baby and the situation in the neonatal unit. Where possible, information should be passed on in an appropriate, private setting. Parents should also be given the opportunity to have support, either from other family members or through external support organisations.”

Ultimately, the review makes 17 further recommendations under phase 2 of its investigation.

It says Trusts should develop communication plans for incidents including arrangements for engaging with families and establishing arrangements for independent validation of self-assement processes for water management.

Trusts should also keep evidence of compliance and up to date registers of staff with water management responsibilities. It should also ensure written water management schemes are up to date and that Water Safety Plans for Legionella, Pseudomonas and other ‘opportunistic water pathogens’ are in place.

An action plan for water management and a multi-agency regional plan should also be developed.

The report suggests Trusts should review the governance arrangements for infection prevention and control; review arrangements for sharing and documenting information; develop guidelines for regional teleconferences; and ensure high impact standardised interventions are implemented at all neonatal units.

Staff training needs should also be reviewed and support should be available for staff both during and after incidents.

Finally, the Public Health Agecny (PHA) should establish a weekly health protection alert bulletin for such outbreaks.

Professor Troop said: “The impact of the pseudomonas outbreaks on the families affected was profound, and I wish to reiterate my sincere sympathy to all those affected by these serious and tragic events.

“Through the experiences shared by the families, the review team concluded that there is important learning on how families are communicated with at such a difficult time for them. In certain cases, families highlighted the use of complex language by clinical staff and not being told of the serious consequences of pseudomonas infection. They also said they need to be given information in an appropriate and private setting.”

Professor Troop continued: “Sadly, during serious events such as the pseudomonas outbreaks, communication often suffers. During the review we were concerned by a heavy reliance on informal communication between organisations. We believe there is a need for more systematic and formal communications networks to be established to ensure that information is not lost and reaches those that need it in a timely manner.”