Ward still struggling with hygiene after RQIA intervention

Wall of silence / Part 1

IT TOOK eight months for the RQIA to respond to Gerry Bond’s complaints about ward hygiene after his grandson almost died of an infection and it led to one of its most damning reports, but two years on the ward concerned is still barely making the mark, The Detail can reveal.

In June 2009 it was revealed that after an unannounced inspection carried out by the RQIA at Ward 4F at the Belfast Royal Victoria Hospital (RVH), the Belfast Trust were making the decision to close the ward for refurbishment.

The RQIA’s findings were widely reported in the media as one of the worst the regulatory body had ever seen with 122 hygiene failures, but behind these figures was a personal campaign by Gerry Bond, who was horrified that it had taken so long to get the inspectors in in the first place.

Now, two years on, The Detail has learnt that there are still flaws in the system and the same ward is still falling short of expected standards.

The RQIA was made aware of hygiene failings in RVH in October 2008 when Gerry Bond first contacted it, but it did not act until the following May.

Belfast Trust has told us that from October 2008 to May 2009, Ward 4F had 5 positive reports of Clostridium difficile toxin, a so-called hospital superbug and one of the most lethal.

This ward would eventually close because of the appalling conditions.

We can now reveal new findings which place a questions mark over the current conditions of the newly re-opened Ward 4F.

From January 2010 to July 2011 Ward 4F had another 4 Clostridium difficile toxin positive reports and 1 MRSA bacteraemia report.

A WALL OF SILENCE

In March 2008, Gerry Bond’s grandson was admitted to the Royal Victoria Hospital (RVH) to undergo surgery to remove a tumour from his brain. Within a few hours, his condition had stabilised and Gerry’s grandson was placed in Ward 4F.

Gerry and his family gained much comfort from the fact that the neurosurgical unit on ward 4F had a reputation as being one of the best in the world. All this would change dramatically only two days after the operation.

After six days, he could not speak and could move only one foot. He was lying in the high-dependency unit, fighting for his life. That was not caused by a clinical problem, it was not some tragic surgical error, and it was not even MRSA. His condition was caused by common everyday bacteria deep inside the surgical site.

Gerry would spend the next year fighting through a wall of silence and evasion from the very bodies that were charged with running and regulating the unit. Questions still remain unanswered as to how this could have happened in the most prestigious unit in the Province’s premier hospital.

CHECKS AND BALANCES

The Quality Standards for Health and Social Care Oder (2006) places a legal responsibility on Health and Social Care Trusts to the quality of care they provide meets the required standard. It states that each HSC should have “properly maintained systems, policies and procedures in place which are subject to regular audit and review to ensure “promotion of general hygiene standards and prevention, control and reduction in incidence of healthcare acquired infection and other communicable diseases”.

The Belfast trust has an environmental cleanliness policy that requires them to set up protocol procedures and practices to maintain hygiene to protect the lives of their patients, the staff and visitors. (see bottom of story for two graphs that Gerry designed to represent what he sees as the failures in the current system)

For example an operating theatre is supposed to have an audit once a week. Using a series of Freedom Information Requests, Gerry asked for copies of the hygiene audits for neurosurgical theatre 1, where his grandson was operated on. It took four months, but he discovered that, prior to the day of his grandsons operation, that theatre had not been audited for 23 consecutive weeks.

Gerry said: “I like to think I’m a logical person I started of looking at what the law requires of the hospital in terms off duty of care and what I discovered was that yes the Belfast trust had these procedures in place but in many instances they were being ignored.

“I am quite sure that the Royal’s administration will claim that that was all down to a systems failure. It is not a systems failure; the systems are all there. It is a governance failure.”

Gerry eventually discovered that over the course of 18 month there should have been at least 18 audit reports averaging at once a month. Ward 4F only had five audit reports for this length of time and each time it fell short of the minimum 75% pass mark.

“Within that system, when there was a failure, to either reach compliance that should have led to an automatic upgrading of how regular the audits were. It should have went from one month to weekly and it should have continued weekly until such time that three consecutive audits reached the minimum requirement. That never happened.

“We had one audit in this period that only reached 40% that’s barely halfway to minimum compliance, the doctors room on that ward scored 17% that’s less than a quarter of the way to compliance. That should have led to an increase frequency, it didn’t."

Gerry repeatedly contacted RQIA / Part 2

In 2008, following the outbreak of clostridium difficile in the Northern Trust area, RQIA was tasked with conducting infection prevention/hygiene inspections at hospitals across Northern Ireland. The results Gerry had received from the Royal were so bad that he made the decision to contact the Regulation and Quality Improvement Authority (RQIA) driectly, which said that it had no prior knowledge of the issue.

Gerry had sent the RQIA five e-mails over an eight-month period that started in October 2008, and had attached copies of the appalling hygiene results. He became increasingly frustrated at their lack of action.

“I pointed out that the incidents were potentially lethal and asked for RQIA personnel to go into the Royal and check that my findings were correct. They sat on their backsides for eight months and did nothing. I made the decision then to go to the media.”

“When they finally did go in — I suspect after being approached by the media — the audit of ward 4F was so bad that it had to be closed: a top neurosurgical ward in a premier hospital had to be closed after a hygiene inspection.”

NOT IN A BLAME GAME

Gerry Bond previously give evidence to the Health Committee

Gerry Bond previously give evidence to the Health Committee

The RQIA carried out its investigation at the end of May 2009. A total of nine neurosurgery beds at the west Belfast site were subsequently closed and it was outlined that the ward was being closed for “refurbishment”. Gerry could find no prior plans for a refurbishement on the site dating to before the inspection.

In November 2009 at a health committee evidence session with the RQIA on Hygiene and Infection Control in the Belfast Trust, a senior representative of the RQIA told the committee for health, social services and public safety that they had identified ward 4F as requiring “immediate attention” to address problems with the condition and cleanliness of the environment and staff practice.

Gerry was also at the committee meeting as well as representatives from the Belfast Trust; he became increasingly frustrated at what he was hearing.

“It had taken more than eight months to get to this point and throughout that meeting the RQIA were selling it as if they had acted straight away. Then the director of medical services at the Royal at the time had said ‘we are not in a blame environment , we won’t be taking disciplinary action’. Meanwhile the health committee agreed that things should never have got to this point, but were basically saying ‘we can’t act – but you can’.

“I’d like to know when something goes drastically wrong who is responsible. Who has the power to say this has got to stop, because until we get that in Northern Ireland, we have no real protection.”

Old worn clinical handwashing sink in ward 4F

Old worn clinical handwashing sink in ward 4F

Within the statutory sector the powers of the RQIA are limited. If they identify any concerns through inspections – they can only make recommendations for improvement, which will be presented to the relevant trust or HSC Board. Where areas of particular concern are identified, RQIA may escalate the issue and refer directly to the chief executive of the HSC board or trust. In addition RQIA may also refer an issue to the minister recommending special measures to be taken.

In a statement to The Detail, the RQIA said:

“When the RQIA receives a complaint about a particular health and social care body, the standard procedure is to refer this complaint to the relevant organisation (on this occasion, the Belfast Health and Social Care Trust). RQIA outlined the correct complaints procedure to the complainant and informed Mr Bond that if he was dissatisfied with the trust’s response, he could refer his complaint to the NI Ombudsman.”

Dr. Frawley has been Northern Ireland Ombudsman since 2000

Dr. Frawley has been Northern Ireland Ombudsman since 2000

REGULATING THE REGULATOR?

In a recent interview with The Detail, the NI ombudsman, Dr. Tom Frawley, indicated that if his office was granted the power to initiate its own investigations its gaze could fall on the processes of regulation within the health service in Northern Ireland.

“I think it’s always good to shine a light in places that don’t get as much public sort of examination, so there are areas which I think are relevant. I mean closed institutions are particularly difficult. Clearly there are issues around the care in hospitals that are long stay for example, or settings that are long stay. Some of the more complex parts of the bureaucracy that are hard for people to understand and that I think could prove fruitful. I think some of the most vulnerable people are fairly marginalised.

“I should acknowledge that I worked in the Health Service for 30 years so I have a fair sense of the difficulties and challenges presented. So there’s a balance to be struck, but I still think they can be supported also by virtue of these examinations because I would argue that this office can be a sword and it can be a shield. And it can be a shield to people who are providing these services to give the assurance to them, and those who are responsible, and part of their family lives that everything is being done that should be done.”

Gerry Bond believes that while the Ombudsman’s comments are helpful, a single body dedicated to the regulation of health only, would be more effective.

He said: “Some form of dedicated Health Ombudsman would definitely be a step in the right direction, and if the NI ombudsman is expressing an interest on how these processes are carried out that can only be a good thing. But I think we need a patient’s council in Northern Ireland or a patients association like England which has nothing to do with health service its funded privately that is desperately needed. It needs to be separate, funded by perhaps a separate government department so this is not coming out of the health budget. So people have confidence and that we need our hospitals as places that we can trust and at the moment we can’t.”

RQIA were recently involved in the development of a new regional standards for hygiene and infection control as well as a review of the department’s Cleanliness Matters Strategy. These were approved by the Minister in early July 2011. There were 29 individual inspections conducted during 2010 at acute, maternity and mental health facilities across all five HSC trusts. Since this time a further 30 inspections have been conducted – these reports are still pending publication.

However the last time RQIA gave evidence to the Northern Ireland Assembly Committee for Health, on the issue of hygiene and infection control was on the 26 November 2009. This was the same meeting Gerry Bond gave evidence at almost two years ago. He remains sceptical about whether or not this commitment to re-examine how hygiene and infection control is managed will make any real difference.

"greater powers needed" / Part 3

“more stringent powers will only solve the problem on one condition, that they are used effectively. You could put a thirty mile an hour sign up at the entrance of any town, that doesn’t stop me speeding what stops me is when the man in the dark green uniform stands out puts his hand up and says there you go sixty quid fine, that’s what stops me. If you’re not going to enforce the regulations then throw them out the window, because they’re not worth having.”

The Detail understands that the RQIA did not reinspect ward 4F before it reopened, in fact despite the appalling findings of its original report they did not look at the ward again for over 12 months. The ward was reinspected in May 2010 and according to RQIA showed a significant improvement on the situation in May 2009. The report said:

“The follow up inspection evidenced a move from an overall minimal compliance level in both areas to a compliance level in Ward 4F and a partially compliant level in the Accident and Emergency department. It is notable that Ward 4F has increased compliance from having six minimally compliant areas to compliant in all areas. The vast majority of the risk factors identified at the previous inspection had been addressed in Ward 4F.”

LATEST HYGIENE REPORT FOR 4F

Gerry has had access to the latest internal hygiene report results from the new Ward 4F and despite all the refurbishment, in many cases it is barely reaching the acceptable score to pass.

When the ward reopened it was moved from high risk category to the same level as an operating theatre – very high risk. When an area is designated as “Very High Risk”, it means the required environmental cleaning standards are of critical importance to service user care. Required standards will only be achieved through intense and frequent cleaning. In these functional areas, service users are at high risk of infection and a frequent and responsive cleaning service is essential.

It also means the area should be subject to an audit once a week, the compliance level breaks down so that 85% equates an acceptable level. The results from the 1st May 2011 to June 2011 show that many of the audits are just about reaching the 85% compliance level.

On the 17th of April this year the ward achieved a score of 85%, by the end of that month it was still only scoring 86.81%. On the 6th June the score was once again at 85% , only rising slightly to 86.52 % two weeks later.

Gerry believes there is a culture in the system that facilitates the bare minimum.

He said: “This idea of a target you can’t reach- to me is nonsensical. There’s only one target when it comes to my health, my families health or anyone’s health for that matter, and that’s perfection. We may not always reach it, but that should be the target. I think the big problem is there is a mindset here that all we have to do is put something down on paper at the bare minimum and everything will work out.

“I would love to see the RQIA go back into the ward or better still an independent body, go back in. But the problem is that the internal hygiene audit uses one system to get the results and the RQIA uses another, so how can you compare? It’s ridiculous.

“I’m not the expert here, but what I do know is that at the minute the regulatory processes that are in place for our hospitals our not fit for purpose, It’s not even a complaints procedure. In my opinion it’s a management protection. I believe it contributes nothing whatsoever to patient safety, it does contribute to protecting senior staff, and that is priority in the system we have at the minute unfortunately.”