Neonatal ward hygiene issues unresolved in lead up to baby death

hygiene failures went unresolved for weeks

hygiene failures went unresolved for weeks

SIGNIFICANT hygiene failures in Altnagelvin Hospital’s neonatal unit went unresolved for weeks and sometimes months in the lead up to the Pseudomonas outbreak, it can be revealed today.

Information on the hospital’s handling of hygiene failures flagged up in regular audits are contained in internal reports The Detail requested from the Western Health Trust using Freedom of Information (FOI) legislation.

The documents show a flurry of activity in response to hygiene failures noted in the reports in the days leading up to and following the first Pseudomonas baby death within the unit on December 10 2011.

Before this, many hygiene failures appear not to have been acted upon. When asked to comment on this issue a trust spokesman claimed that the “vast majority” of actions were completed and said “IT issues” were the reason this information had not been included in the reports.

A previous article by The Detail revealed sink hygiene failures in the neonatal Intensive Care Unit at the Royal Jubilee Maternity Hospital (RJMH) in in Belfast in January 2012 – just days before the first baby death at that location.

Pseudomonas can cause breathing difficulties and tissue damage. It is believed it can take hold in areas such as sinks and in water pipes with stagnant water. The bacteria can live for several days on surfaces but can be eradicated by vigorous hand-washing.

Sink taps emerged as the source of the Pseudomonas infection which killed three babies at the Belfast hospital. The interim report by the RQIA led review team, into the outbreak confirmed that the taps in Altnagelvin’s Intensive Care Unit (ICU) also tested positive for Pseudomonas.

In contrast to the audits carried out at The Royal, the hygiene audits for Altnagelvin show that most of the taps and sinks were consistently passing the audits in the neonatal unit.

However, any issues that were highlighted were not resolved until either the days leading up to or following the first baby death. In some cases the issues had been flagged up months before.

The results also show that in the months and weeks leading up to the outbreak, the clinical equipment in Altnagelvin was constantly failing in areas like the High Dependency Unit (HDU) and the Special Care Baby Unit (SCBU). There were also failures with the boiler and water dispensers as well as soap dispensers and hand washing facilities.

Most of these issues were not resolved until after the first case of Pseudomonas was confirmed.


By November 28 a urine test for a baby being cared for in the ICU room of Altnagelvin Neonatal Unit was found to be positive for Pseudomonas.

The baby developed Pseudomonas infection of the skin and blood cultures were sent for testing. On December 2 2011, the baby was transferred from Altnagelvin to RJMS’ intensive care unit in Belfast for treatment of another condition.

Meanwhile, back in Altnagelvin’s neonatal unit the condition of a second baby who had been very unwell since birth deteriorated in the ICU room. Blood cultures were taken and on December 8 2011 were reported by the laboratory to be positive for Pseudomonas. The baby did not respond to treatment and died on December 10 2011.

This was the first baby to die in this latest Pseudonomas outbreak.

The Neonatal Intensive Care Unit (NICU) is classified as a very high risk functional area that requires weekly environmental audits.

The audit reports obtained by The Detail show that Altnagelvin’s neonatal unit had a high overall pass rate for hygiene.

However, closer inspection of the failures within the results reveal a worrying trend which puts a question mark over how often the results were being assessed.

Data for Altnagelvin on the October 4 shows that the Neonatal Intensive Care Units (NICU) ice machine/hot water boiler/water fountain failed the hygiene audit because there was a “build up”. The reports show this was not resolved until December 10.

On the October 18 in the bedded area of the High Dependency Unit (HDU) in the NICU the audit shows that equipment on high surfaces failed because of dust.

Again on the October 25 the specific cot area sink failed the hygiene audit in the Special Care Baby Unit (SCBU) of the NICU.

The hospital’s results show that none of these failures were “completed” until December 11, the day after the first baby died at Altnagelvin.

The hygiene audits for Altnaglevin also show that on the November 1 the bedded area of the NICU’s High Dependency Unit failed because internal glazings including partitions were “smeary”. Again, action was not taken until the December 11. Clinical equipment also failed, but no date is given for when this failure was addressed.

On November 8, the soap dispenser in the Special Care Baby Unit (SCBU) was noted as being below standard, the completed date for this is marked as December 12. On the December 6 medical equipment as well as dispensers and holders were noted as failing once again. The soap dispenser was also highlighted as needing action but there is no confirmation of when or if this was completed.

Hugh Pennington is a professor of Bacteriology at the University of Aberdeen and a leading expert in Pseudomonas. He has followed events in Northern Ireland closely since the first outbreak was confirmed.

The Detail passed on copies of Altnagelvin’s neonatal hygiene reports to Professor Pennington to ask for his expert opinion.

After examining the detailed documents released to us, he said he was concerned about their content.

He said: “Any problems that an audit finds around the handwashing issue in general, particularly with wash hand basins or soap dispensers is really very disappointing. Particularly in any kind of high dependency unit.

“There really shouldn’t be an issue with those kinds of things. They should always score 100%.

“It doesn’t guarantee safety by any means, but it is the bottom line – there’s no excuse for it really.

“We need to know how quick the hospital is to respond to a problem and how soon does it know that there is a problem to which it should be responding.”

The first stage of the RQIA led review into the outbreak was published at the start of April and is headed up by Professor Pat Troop, former chief executive of the Health Protection Agency. This report addressed the causes and impact of the outbreak, with the full report due by the end of May.

The Troop report found slight variations in cleaning methods and risk assessment within each health trust and also in the frequency of cleaning.


There were a number of inconsistencies in the internal hygiene audit documents we received from The Western Trust.

The first two weeks of December 2011 were missing a ‘failures sheet’ which is usually provided at the start of each monthly hygiene report to give a summary of any issues picked up by that particular audit.

We contacted the Western Trust about this issue and they claimed that the absence of the ‘failures sheet’ was due to the electronic system experiencing “technical difficulties” which meant that only manual audits could be supplied.

In a statement to The Detail The Western Trust confirmed that some of the audits we received in response to our FOI request had been sourced from the traditional manual system up to September 2011 and for a two week period in December due to “IT issues”. The remainder were from a new electronic system the trust was using as a data collection tool – the ‘Maximiser’ system.

A spokesman for the trust said: “The Maximiser system is presently being rolled out throughout the trust’s hospital wards and departments. This has required a significant investment in staff training and awareness and is still on-going.

“When fully implemented, the system will provide instant access to reports and action plans to monitor environmental cleanliness.

“However, in the short term this does mean a period of transition for staff who are becoming familiar with the use of the new system. During this time both manual and electronic auditing are being used.

“Altnagelvin NICU began to use the new electronic system in September 2011, however not in real-time as this was a period of familiarisation. This means many actions were completed but not entered on the system at the time of completion.

“This explains the pattern which is evident in early December 2011 of a series of sign offs. Having checked all the individual issues highlighted by The Detail, the trust can confirm that the vast majority of actions were completed.”

However, Professor Pennington believes many questions remain about the effectiveness of the current hygiene audit system.

He said: “We have to ask how good are they in the first place and also if they can give a false sense of security.

“Sometimes high pass marks are covering up deficiencies.

“Staff training is crucial in the culture of the institution. Logically you have to ask the question, were the audits fit for purpose?

“We know now that essentially the audits were not auditing what the problem was. The bug was in the tap water.

“I think this set of circumstances took people by surprise and that’s why there were the tragedies. When you’re controlling an outbreak, the essence is speed. “

The Western Trust said that the issue of whether or not the trust followed regional guidelines and advice for water systems management is one that Professor Troop and her team of experts will examine and comment on when they publish their final report at the end of May 2012.