Scotland: Massive public health failings responsible for CDAD deaths at Vale of Leven hospital

It has now been established that some 3,145 people contracted Clostridium difficile associated disease (CDAD) in Scottish hospitals in the six months between December 2007 and May 2008. Of these 285 died, with CDAD being cited as the underlying cause of death in 86 cases and a contributory factor in 199, a fatality rate of 9 percent.

The extent of CDAD emerged from reports commissioned by the Scottish government following a public outcry over CDAD-related deaths in one hospital, the Vale of Leven Hospital, in Alexandria, near Glasgow.

The reports make clear that the danger of CDAD is by no means restricted to the Vale of Leven, and that its source lies in the systematic undermining of public health by successive UK and Scottish governments.

Clostridium difficile is a known quantity, first discovered in 1935. Along with the anti-biotic resistant strain of staphylococcus aureus (MRSA), the bacteria is one of the so-called “superbugs” which have emerged in recent decades as resistant to many commonly used antibiotics. Present naturally in around three percent of human intestines, the bacteria become dangerous if anti-biotic, or other treatment or medical conditions, has destroyed rival intestinal microbes. Under these conditions, the bacteria can rapidly spread, causing diarrhoea, colonic ulceration and perforation, fatigue, severe dehydration and blood poisoning. CDAD can be particularly dangerous for elderly people or weakened patients.

While there are a range of treatments available for CDAD, the most important medical response is to control the spread of bacterial spores to prevent infection being transmitted to other vulnerable patients. Spores, which are broadcast from infected faeces, are resistant to ordinary disinfectants, and have been shown to be able to survive in the open air for up to two years. Preventing transmission of the disease, therefore, depends on a rigorous, long-term infection control regime.

But the reports make clear such a regime was absent in many hospitals.

At the Vale of Leven Hospital, a team of public health academics and a microbiologist were tasked with identifying why death rates from CDAD at the hospital (18 people died out of 55 who were infected) were significantly higher than the average. The fatalities were mostly older people recovering from a range of conditions, but who were sufficiently weakened to be unable to combat CDAD.Their report found that the threat of closure which had been hanging over the hospital for more than 10 years had meant it had not been sufficiently upgraded and maintained.

The Vale of Leven had been a popular local hospital. However, Labour’s spending cuts—under the guise of “re-organisation”—saw a host of proposals brought forward, including its eventual closure, which led to continuous uncertainty as to its future.

The consequence of this, the report notes, was “...the capacity of the hospital to effectively isolate CDAD patients was limited due to lack of suitable facilities for effective infection control practices such as appropriate bed spacing, single rooms and hand wash basins.”

Based on evidence, including testimony from family members of those affected and hospital staff, the report outlined a catalogue of basic practical deficiencies:

* Family members, who took soiled laundry home to wash for patients, were given no instructions on the dangers associated with CDAD. Few patients were given hospital nightwear. Visitors were given unclear advice on contact with patients.

* Different approaches to infection were taken on different wards. Some staff appeared to be unaware that that soap and water was needed to combat infection, instead of the readily available alcohol gel.

* Beds of infected patients were packed together in badly ventilated and over-heated wards. There was also a lack of hand wash basins, ward cleanliness was inconsistent and the hospital was in a generally dilapidated state.

In addition, the integration of the disbanded Argyll and Clyde Health Board into the Greater Glasgow and Clyde Health Board, revealed “a lack of clarity and leadership in several key roles and responsibilities, committee structures and lines of reporting.”

The Argyll and Clyde Health Board had been responsible for health care over a hugely dispersed area of nearly 3,000 square miles and a population of over 400,000—during the course of which it ran up a debt of some £80 million.

In 2005, the response of the Scottish Executive, then controlled by the Labour Party, was to close down the board and split its debt and responsibilities between two successor authorities, including the expanded Greater Glasgow and Clyde authority.

Commenting on the report, leading bacteriologist and commentator on infectious diseases, Professor Hugh Pennington noted “I have no doubt that initially people were infected because of the conditions there. Dirty toilets, patient areas not having wash hand basins, these are fundamental conditions which allow C.diff to spread.”

“We learned all this in the 19th century and it’s crazy these things are still going on. All these deaths in a small hospital—you can only explain that as there being something seriously wrong with the place.”

Ample warning

The second report, by Health Protection Scotland (HPS), made clear that conditions at the Vale of Leven were replicated in other areas. Aberdeen Royal Infirmary, Kirkcaldy, Wishaw, the Victoria Infirmary in Glasgow, and Woodend in the Grampian region were also reported as having higher-than-average infection or fatality rates.

It also noted general weaknesses in reporting CDAD cases and deaths. Remarkably, the report suggested that there were local inconsistencies in reporting the cause of death on death certificates. While each health board had its own methods of reporting levels of infection, these were not consistent across regions. Other than through death certificates, there was no reliable means of monitoring CDAD instances.

Ample warnings were available of the dangers of CDAD. There had been a drastic increase in CDAD infections in England, from around 1,000 annually in the early 1990s to 44,488 in 2004, largely due to similar circumstances to those outlined in the Vale of Leven report. In Kent alone 90 people died as a result.

In 2005 Paul Grime, a member of the British Medical Association’s occupational health committee, noted: “If we are successfully going to tackle hospital-acquired infections, we need a co-ordinated approach across the whole hospital community—doctors, nurses, cleaners, managers, patients and their visitors all taking action on hygiene...”

Despite this caution, a July 2007 report prepared by HPS, disclosed that almost 10 percent of hospital patients were acquiring some form of infection, including CDAD, in hospital, in addition to whatever condition had brought them to hospital in the first place. In one hospital, Stobhill in Glasgow, infection rates were closer to 20 percent.

In February 2008, eight months later, an internal document from HPS complained of a “lack of guidance” over how Scottish health authorities should respond to the warnings from England. Scotland on Sunday acquired the document which showed that an HPS official attended a meeting in London on the scale of the problem. The official communicated his concerns on his return.

Yet in June 2008, sources close to Scottish National Party Health Minister Nicola Sturgeon said neither she, nor health department officials, had any knowledge of new guidelines for combating CDAD which were being implemented in England, in the aftermath of the 2004 deaths. The guidelines appear to have resulted in some reduction in CDAD deaths

Clearly frustrated at official indifference, Pennington at the time noted “Bugs don’t stop at Gretna [a town on the border between Scotland and England]. But the Department for Health in Scotland appears to have been far more laid-back than their counterparts in England.”

Pennington continued, “The seriousness of the problem would have been much less and the number of deaths would have been much less,” he said.

Yet a few weeks later in July, Sturgeon claimed that “Scotland has one of the most comprehensive sets of policies and procedures to manage hospital-acquired infections in Europe.”

With the publication of the reports, the SNP is attempting to circumvent calls for a full public inquiry into the circumstances surrounding the deaths at the Vale of Leven.

Sturgeon has passed the reports over to the Lord Advocate—Scotland’s chief legal official and a political appointee—to see whether Glasgow and Clyde Health Board should be prosecuted.

While Glasgow and Clyde Health Board may bear some responsibility, Sturgeon’s move is nevertheless a blatant attempt to pass the buck. By seeking to attribute the Vale of Leven outbreak to health board failings, the SNP hopes to obscure the broader and more fundamental issues raised by the gutting of health care in the service of the market.

The consequences of this were shown in the announcement earlier this week that a hospital ward at Queen Margaret in Dunfermline, Fife has been closed following an outbreak of C.diff.