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Clostridium Difficile Outbreaks at Stoke Mandeville Hospital and Publication of Data on Healthcare

Volume 449: debated on Monday 24 July 2006

The Healthcare Commission has today published its investigation into outbreaks of clostridium difficile at Stoke Mandeville hospital (Buckinghamshire Hospitals NHS Trust). Copies of the report have been placed in the Library.

My right hon. Friend the Secretary of State commissioned this report to establish:

whether the trust's systems and processes for the prevention and control of infection were adequate during the two outbreaks;

the current state of the trust's systems to control this infection; and

the lessons to be learned from these outbreaks, both for the trust and the wider NHS, about how best to reduce the risk of C. difficile infection.

The Healthcare Commission's report identified the factors involved in the first outbreak and concluded that a failure to implement appropriately the lessons learnt from this, combined with an inadequate governance system, led to a delay in controlling the second outbreak. Since the outbreaks, the trust has improved infection control practice and consequently strengthened patient safety.

My right hon. Friend has today written to Anna Walker, Chief Executive of the Healthcare Commission to accept the conclusions of the report. This letter also asks that the Commission use the powers available to it to ensure that trusts are following the good practice set out in the new Code of Practice on Prevention and Control of Healthcare Associated Infection and to use their powers of intervention where trusts fail to do so.

The Department will work closely with the trust, the strategic health authority, the Health Protection Agency and the local primary care trusts in addressing the recommendations in the report. As the conclusions have a wider applicability to the health service, the Chief Medical Officer and Chief Nursing Officer will consider this report over the summer and assess how the lessons learned can be implemented both locally and nationally to reduce the risk from this infection. The Department will also ensure that the report's conclusions inform the review of the current C. difficile guidance.

Today also sees the publication of the latest information from the Department of Health's mandatory healthcare associated infections (HCAIs) surveillance system. This information, which has been placed in the Library, brings together data on MRSA blood stream infections, clostridium difficile associated disease, glycopeptide resistant enterococci blood stream infections and orthopaedic surgical site infections to help assess trends in HCAIs.

This statistical report has been prepared by the Health Protection Agency (HPA) and is a part of our new approach to publication of HCAI data, where the HPA both manages the surveillance programme and publishes the data. An annual report will be produced every July to help evaluate trends and facilitate access to all the data.

Mandatory surveillance has shown a clear need to improve NHS performance and we believe that upgrading the level of surveillance and more rapid feedback of results will help performance. Therefore we intend to move to quarterly publication as soon as it is feasible to do so.