Inquiry Report
The Inquiry Panel delivered their Report to Minister Michael McGimpsey on the 4th March 2011.
The Report was then published on the 21st March 2011.
Inquiry Report
Section 1 - Introduction
Section 2 - Context
- Chapter 3 - The Trust (PDF 1.3MB)
- Chapter 4 - The Outbreak (PDF 791KB)
- Chapter 5 - Death Certification (PDF 460KB)
- Chapter 6 - Clostridium difficile infection (PDF 70KB)
Section 3 - Findings
- Chapter 7 - Death from Clostridium difficle infection as a result of the outbreak (PDF 53KB)
- Chapter 8 - Experience of patients and relatives (PDF 889KB)
- Chapter 9 - Experience of staff and the Trust (PDF 121KB)
- Chapter 10 - Changes and developments since the end of the outbreak (PDF 48KB)
- Chapter 11 - List of recommendations (PDF 168KB)
- Abbreviations (PDF 36KB)
- References (PDF 57KB)
Appendices
- Appendix 1 - Statement of purpose (PDF 1.5MB)
- Appendix 2 - Reviewers' report on first term of reference (PDF 6MB)
- Appendix 3 - List of inquiry witnesses (PDF 31KB)
- Appendix 4 - Core participants (PDF 35KB)
- Appendix 5 - Expert witness statement on Clostridium difficile; antibiotic associated diarrhoea (PDF 8.12MB)
- Appendix 6 - Expert witness statement on communication with patients in hospital (PDF 3.46MB)
- Appendix 7 - Expert witness statement on infection prevention and control (PDF 326KB)
- Appendix 8 - Expert witness statement on end of life care (PDF 3.87MB)
- Appendix 9 - Expert witness statement on communication and public relations (PDF 8.48MB)
- Appendix 10 - Expert witness statement on communication with and support for staff in hospitals under normal working conditions and during an organisational crisis (PDF 6.61MB)
- Appendix 11 - Press notice and public notice (PDF 4.42MB)
- Appendix 12 - Questionnaire (PDF 3.68MB)
- Appendix 13 - Themes (PDF 29.7KB)
- Appendix 14 - Budget expenditure (PDF 31KB)
- Appendix 15 which includes all witness statements can be accessed through the Written Evidence page.
