---

Clostridium Difficile

The Healthcare Commission's report on the outbreaks of clostridium difficile at Maidstone and Tunbridge Wells NHS Trust is a truly shocking document. On behalf of the Government and the national health service, I would like to apologise to all those who have been personally and directly affected, and to offer my condolences to the families of those who have died. Clostridium difficile is the major cause of serious bacterial infectious diarrhoea. It can colonise the gut, causing inflammation of the colon and in the worst cases it can prove fatal. It is normally controlled by the presence of other bacteria, but when those are killed—for example, by antibiotic treatment—it can grow and cause disease. Tackling health care-associated infections is a priority in the NHS operating framework. In October 2006, the code of practice on the prevention and control of health care-associated infections became a statutory procedure. We have made it clear that tackling HCAIs should be a priority for all local NHS organisations, and the aim is to reduce the number of C. difficile infections by 30 per cent. by March 2011. Mandatory surveillance of C. difficile infections was extended to people aged two and over from April this year—previously it applied only to patients aged 65 and over—to help with local monitoring. We have doubled the number of improvement teams that are helping trusts to reduce hospital-acquired infections. We have announced deep cleans within all trusts, and we have published new guidance on uniforms so that staff are bare below the elbow. That assists with hand-washing, which is crucial in countering such infections. We are also creating a new regulator with stronger enforcement powers, who will be expected to inspect, investigate and intervene on health care acquired infections. In July, we made an additional £50 million available to reduce HCAIs. The MRSA cleaner hospitals action plan has been expanded to cover clostridium difficile. It has already had an impact on efforts to tackle MRSA, and it is expected to have a similar effect on C. difficile. While all those measures are crucial, the report from the Healthcare Commission on Maidstone and Tunbridge Wells NHS Trust shows that we need far more vigilance and determination in our drive to eradicate hospital-acquired infections. The NHS chief executive has written to every NHS trust today, appending the Healthcare Commission's report seeking reassurances from every NHS chief executive that infection control is regarded as a major priority in every NHS organisation. We established the Healthcare Commission in 2003 to ensure continuous improvement in health services and to undertake specific investigations into trusts when allegations of serious failings are raised. Because Maidstone and Tunbridge Wells NHS Trust had consistently been among the 25 per cent. of trusts with the highest rates of C. difficile since mandatory surveillance began in January 2004, the strategic health authority proactively asked the commission to undertake that investigation in July 2006. The commission interviewed more than 200 past or present staff, and it also reviewed in detail the case notes for 50 people who contracted C. difficile on admission to the trust and then died. The Healthcare Commission report reveals significant failings in efforts to stop the spread of C. difficile. If the 50 cases reviewed were representative of the 345 people who died, and if one extrapolated from the reviewer's assessments, C. difficile was probably or definitely the main cause of death in approximately 90 of the 345 cases, and definitely the cause in 21 cases. The Healthcare Commission found that the trust board was unaware of the high infection rates, and did not spend enough time considering issues relating to infection control. The commission's report made it clear that the individual appointed director of infection prevention and control did not have any real understanding of their role from the outset. Management of the infection control team was considered inadequate, and there was confusion about who actually managed the team. Overall, the governance system that was intended to bring clinical risk to the board's attention did not function effectively, and the board appeared to be insulated from the realities and problems occurring on the wards. The Healthcare Commission makes recommendations for action by the trust, including reviewing its board leadership; the priority of infection control at board level; risk management; clinical guidelines; and staffing levels and training. Those actions will be performance-managed by the strategic health authority. Following the recommendation of the Healthcare Commission report, the South East Coast strategic health authority has commissioned an independent review into the leadership of the trust during the period of the outbreaks. An interim report will be made available to the strategic health authority by November. Although employment is a matter for the local NHS trust board, I have instructed the trust in this exceptional case to withhold any severance payment from the former chief executive of Maidstone and Tunbridge Wells NHS Trust pending legal advice. I can tell the House that James Lee, the chair of the trust, has today offered the Department his resignation, which I have accepted. I have asked the chief executive of the NHS to ensure that a suitable replacement is found so that the trust can move quickly to act on the recommendations of the report and restore public and patient confidence in NHS services locally. In addition to the independent review into leadership at the trust, I have asked the Department of Health to carry out a separate review into the role of the chair of the trust and the decision-making process that led to the terms and conditions of the chief executive's departure. That will conclude urgently, and it will be shared with the Appointments Commission. I am particularly concerned by the Healthcare Commission's assessment that"““The Trust delayed announcing the outbreak and then produced figures that almost certainly underestimated the number of deaths.””" I have asked that our independent report into the trust's leadership at the time of the outbreak examine this specific point. The report identified five national recommendations. It may be helpful to the House if I set these out, together with the actions being taken in response. First, the diagnosis of clostridium difficile needs to be regarded as a diagnosis in its own right, with proper continuity of management. National guidance has been available since 1994, and a revised version taking into account this recommendation will be published shortly. Secondly, the Healthcare Commission said that further consideration needs to be given to the education and supervision of trainee doctors, with a view to improving the recording of clostridium difficile on death certificates. The need for good reporting of health care-associated infections on death certificates has just been reinforced by a chief medical officer professional letter published on 4 October. Further measures will be considered in response to the report. The third recommendation that has national ramifications was that antibiotics should be targeted, at the narrowest spectrum possible, and used for the shortest possible time. We recently published A summary of best practice on this issue, making that very point. The Healthcare Commission recommended that the national health service and the Health Protection Agency should agree clear and consistent arrangements for the monitoring of rates of C. difficile infection. In April 2007, we improved the mandatory reporting of C. difficile by introducing a web-based reporting system and requiring data on two-year-olds and above to be reported. The final recommendation was that the board of every NHS trust must understand the roles and responsibilities of the director of infection prevention and control, and regularly receive information about incidents and trends. The report acknowledged that duty 2 of the hygiene code addresses this issue. The situation uncovered by the Healthcare Commission at the three hospitals is truly scandalous. We must all shoulder our share of the blame, but I hope that the House will recognise that the awful failures in Maidstone and Tunbridge Wells are entirely unrepresentative of the standards of care that patients and the public rightly expect, and which are delivered in hospitals across the country day after day.