The Dudley Group NHS Foundation Trust have carried out an investigation after concerns were raised about the decontamination procedure at the Endoscopy Unit at the Corbett Hospital in Dudley. The Trust reported that dozens of patients have been affected, and a number have suffered life-changing injuries.
What was the problem?
By way of background, an endoscope is a long, thin, flexible tube with a camera and light at one end, which is used to help examine the inside of the body. A cystoscopy is a procedure where an endoscope (or cystoscope) is used to examine the inside of the bladder. The cystoscope is passed into the urethra, the tube which carries urine out of the body. The report by the Trust identified problems in the way the cystoscope was being cleaned, and a number of patients suffered problems as a result.
When did the problems start?
In March 2020, a Consultant informed a deputy matron that out of 8 cystoscopy patients over the past month, 7 had suffered infections after having their procedures. The infection rate of 87.5% was significantly higher than the 2% risk of getting an infection that would normally be expected. A staff nurse also told the deputy matron that there was an unknown ‘white residue’ on the cystoscope itself; we don’t know how long the residue was present for.
On 4th March 2020 a decision was made to stop all cystoscopy clinics. An investigation was carried out, and the scopes were swabbed after being cleaned. The swabs came back as clear of infection, and it was suggested that the ‘white residue’ was likely to be hard water minerals. It was decided to restart the cystoscopy clinic.
On 10th March, after further affected patients were identified, the decision was made to swab the individual parts of the cystoscope. During this process, it was found that the hospital staff had not been taking the scope apart properly before cleaning it. A small valve showed the presence of pseudomonas. Pseudomonas is a type of bacteria that is commonly found in soil and water, and which can cause infections in humans. Infections can be difficult to treat, and can lead to serious problems, particularly in the clinically vulnerable.
A new cleaning process was started, to ensure that the valve was cleaned properly. The Trust reported that their previous cleaning process would have left ‘gross debris’ on the scope, which would increase the chance of spreading disease.
On 15th July 2020, a further case of pseudomonas was found in a patient who had recently undergone a cystoscopy. A meeting was held at the end of August, when it was decided to find out exactly how many patients had been affected and to write out to them to inform them of the problems that had been identified.
A meeting took place on 29th September, where concerns over the sinks within the Endoscopy Unit were raised. The water outlets/ports were not being flushed, and pseudomonas were found in the water being flushed through the scope from the sink in the clinical area. A survey of the area was carried out, which revealed dirty curtains and blinds, dirt ingrained into the floor, lime scale build up on the taps and part of one sink that needed resealing. It was decided to replace the sink in the clinical area as soon as possible, and for the sinks and carpets at the Corbett to be replaced over the longer term. The Unit also started to use sterile water to clean the cystoscopies, rather than water from the sink.
The Trust carried out a ‘Root Cause Analysis’ report (RCA) into what happened, finalising their report in October 2020. It was reported that the above actions, together with a regular monitoring plan, would help resolve the problems that had arisen.
How have patients been affected by what has happened?
The report focussed on patients treated between October 2019 and July 2020. The report identified a range of injuries that had been caused by the cleaning failures. Dozens of patients developed pseudomonas infections and needed treatment as a result. Sadly, some of those patients came to serious harm, with problems including the development of sepsis, haematuria (blood in the urine) and orchiectomies (removal of one or both testicles).
It remains to be seen as to exactly when the decontamination problems started, and when patients were placed under unnecessary risk as a result. Is the Corbett Hospital the only hospital with these issues? The Healthcare Safety Investigation Branch (HSIB) has recently launched its own investigation into the decontamination of surgical instruments; how widespread therefore is this problem?
For those patients who have been affected, it is very difficult to get peace of mind as worry will no doubt ensue as to whether the pseudomonas might cause any other problems, and indeed whether anything else might have been passed on between the affected patients.
What if you have been affected?
The Trust should have sent you a recall letter, although it’s always possible that patients may have been missed from the recall procedure. The Trust may also have sent you a copy of their Root Cause Analysis report, and invited you in for a review appointment. You may therefore already have some answers as to what’s happened to you. If you want some legal advice about your options, if you or a family member has been affected, the next step will be to contact a member of our medical negligence team.
Our specialist team of experienced lawyers can advise you as to your options. We already act for a number of affected patients, and we will help you obtain the answers you need and the compensation you deserve. We have offices at the Waterfront near Merry Hill, as well as in Dudley and Kingswinford town centres. We also offer home, video and telephone appointments if those are easier for you. We will be able to talk through your options with you completely free of charge, and can offer ‘No Win, No Fee’ funding agreements should you want to investigate a case for negligence. If you’d like to speak to one of the team, please click here to arrange a call.
