Health Minister's Statement to the Northern Ireland Assembly on the C difficile Inquiry

Mr Speaker, I wish to make a statement about the Public Inquiry into the Outbreak of Clostridium difficile in Northern Health and Social Care Trust Hospitals. The Inquiry has concluded its investigation and is publishing its report today.

At the outset I want to apologise to all those affected and offer my sincere sympathies to those families who lost loved ones during this outbreak.  

There is no doubt that this 027 strain of C. difficile was extremely virulent and caused a great deal of pain and distress to all those affected.  This outbreak was the first time that the 027 strain was seen in Northern Ireland.  

This Assembly voted in favour of a public inquiry in March 2008. However, while I made it clear that I was minded to commission a public inquiry I first wanted to focus on the RQIA independent review of the outbreak.

In October 2008 I made a statement to the Assembly about the conclusion of RQIA review.  I also advised members that I had decided to commission a public inquiry and set out the two tasks to be undertaken.

Dame Deirdre Hine was appointed as chair of the inquiry, along with other panel members Professor Robert Stout, Dr Jocelyn Cornwell and Eleanor Hayes.  

The Terms of Reference for the Inquiry were:

The Chairman of the Inquiry advised me that she wished to include staff in the Northern Trust as part of the second term of reference and I endorsed this approach.

On the basis of the RQIA’s findings, I asked the Inquiry to examine the period from 16 June 2007 to 31 August 2008.

In going about its work, the Inquiry has not sought to apportion blame. Rather, they have focused on establishing facts, on hearing people’s stories, and on identifying whatever needed to be learned. That is what I wanted this inquiry to do.

During the past 23 months the Panel met in private 30 times; undertook a familiarisation visit to each of the five hospitals involved; held 20 informal meetings with persons directly affected by the outbreak, and held public oral hearings over 14 days in October 2010.

The Inquiry received 73 completed questionnaires, 50 letters, 113 written witness statements and a total of 1,055 documents, including reports of outbreaks elsewhere in the UK.

The report is publicly available on the Inquiry’s website from twelve o’clock today.  The Core Participants in the Inquiry – mostly former patients and relatives – have been given an opportunity to read the report before it is published.

The Inquiry Panel has made 12 recommendations. Of these, nine are for the Trust and three are for the Department.

The recommendations cover aspects such as:

I accept each of the Inquiry Panel’s recommendations.

A team of expert reviewers carried out a detailed independent review of the medical case notes of all the patients who died. A total of 124 clinical records were examined and they concluded that there were 31 deaths during the outbreak for which Clostridium difficile infection was the underlying or contributory cause.

Of the 31 deaths identified, C. difficile was the underlying cause in 15 deaths and a contributory cause in 16 deaths.  

The findings and conclusions presented by the expert group have been accepted in their entirety by the Inquiry Panel.  I also fully accept these findings.

The Inquiry report includes a number of positive comments, showing that high quality care was provided in many instances and in many wards.

However, it is clear that in some areas things happened which fell short of the standard of care that people have a right to expect.

Among the recommendations made are the need for the Northern Trust to improve how it communicates with patients and their relatives.  The Trust Board too have a key role to play in listening to patients’ complaints and taking action when appropriate.  

Patients and relatives have the right to understand what is happening and to know how their concerns are being dealt with at all times.

The outbreak happened shortly after the health and social care service had undergone major reorganisation.  As a relatively new body, the Northern Trust did not have sufficient time to bed down all its governance arrangements and ensure that there were robust lines of communication.  

In situations such as this, there are clearly risks for all HSC organisations in terms of responding to crisis situations.  My Department fully recognises that this is an issue and will ensure it is addressed.

Mr Speaker, the core of the matter is that every patient should be treated with respect, dignity and compassion.

Our health and social care service treats and cares for hundreds of thousands of people every year.  In the vast majority of cases, this care is of a high standard.

Unfortunately sometimes patients do not get the care they are entitled to expect.

It is clear that during the height of this outbreak, public confidence in the health and social care service was shaken to the point were some people were worried about going into hospital because of fears they might contract an infection.  This is not acceptable.

I have made significant investments into driving down the rates of healthcare associated infections such as C. difficile and MRSA.  

As a result, C.difficile levels in our hospitals have halved over the last few years and are now at their lowest level since formal monitoring began.  All Trusts are fully aware of the need to ensure there is a culture of zero tolerance of infections.

The report has emphasised that this is not about dirty hospitals.  The fact is we will never be able to eradicate C difficile.  That does not mean we should not take every step possible to prevent it.

Mr Speaker, I want to assure the public that they can have confidence in the quality and safety of care in all our healthcare facilities.  It is important that this message is heard and that politicians and the media are careful not to cause unnecessary anxiety.   

In their report the Inquiry Panel have appealed for more responsible media reporting, and I hope that the media will heed that appeal.

Mr Speaker, as I have suggested, our focus has to be on everyone who suffered during the outbreak, in particular those people who died and their families.  

In closing I want to say a few words about the Trust.  It is vital now that the Northern Trust is able to continue to improve services and continue to restore the confidence of the community it serves.

I want to thank Dame Deirdre Hine and her fellow Panel members for carrying out the inquiry in such a sensitive and professional way.  I also want to commend the Inquiry on their careful stewardship of public funds.

Finally, Mr Speaker, I want to thank everyone who gave evidence to the Inquiry. For many witnesses, this will have been very distressing but it is their contribution that has given this Inquiry its value and its power.

While the Inquiry has addressed recommendations to the Northern Trust, at the Panel’s suggestion, I will require all the HSC Trusts to carefully consider the implications for their own services and to ensure they implement them.

I will also share the report with Health Ministers in the other UK jurisdictions.   More immediately I am meeting the Chairman and Chief Executive of the Northern Trust this week to set a timetable for implementing the recommendations swiftly.

I want to assure the public that they will be implemented and all lessons will be learned.