NR AFSD
AU Hunter,M.
TI Inquiry into handling of CJD alert welcomed
QU British Medical Journal 2002 Nov 9; 325(7372): 1055
PT news
VT
Inquiry into handling of CJD alert welcomed
Mark Hunter Leeds
The chief executive of Middlesbrough General Hospital welcomed the launch of an
independent inquiry into the hospital's handling of an alert involving Creutzfeldt-Jakob disease (CJD). The alert arose when staff realised that instruments used on a patient who was later found to have the disease had been reused on 24 other patients.
Chief medical officer Liam Donaldson announced the inquiry last week as the Department of Health began frantically backtracking on its initial criticism of the hospital.
Having originally described the possible exposure of 24 patients to a risk of CJD infection as "an appalling incident" that reinforced the need to adhere to its "crystal clear guidance" on decontamination, the department later adopted a more conciliatory tone.
"This is a difficult and distressing situation for all the patients and families concerned, as well as for the dedicated staff at Middlesbrough General Hospital," said Professor Donaldson. "I have asked the regional director of public health, Dr Bill Kirkup, to fully assess the facts and report to me shortly. His report will ensure that any measures necessary to improve local procedures or strengthen national policy are taken."
Meanwhile, the medical director for South Tees Hospitals NHS Trust, Dr Paul Lawler, had made it clear to the press that the hospital had followed the Department of Health's guidance to the letter throughout the incident.
He said that the potential for contamination stemmed from a brain biopsy undertaken in July on an elderly woman who was later found to have the sporadic form of CJD.
"CJD was not suspected in this patient at the time of the operation," stressed Dr Lawler. It was only when a "diligent" pathologist sent a sample of tissue to the CJD surveillance unit "to rule CJD out rather than confirm it" that the diagnosis was made.
In the intervening three weeks the instruments from the original biopsy were used on a further 24 patients.
"Once sporadic CJD was diagnosed we followed the procedure set down by the CJD incidents panel," said Dr Lawler. This meant the immediate withdrawal of £90 000 ($140 000; ? 141 000) worth of drills, craniotomy sets, and surgical instruments.
However, the 24 patients were not told that they were at potential risk of contamination until the story broke in the media last week, 12 weeks after the instruments were withdrawn.
The hospital's managers say that this was because they were waiting for a decision from the government's CJD panel on when and how to contact the patients.
The hospital has now contacted all the patients and will be allocating them "a named person at the trust who will fully support them for as long as they feel they need it."
The trust's chief executive, Bill Murray, said: "We are deeply sorry for any distress caused to the patients and their families and will do everything we possibly can to help them through this difficult time.
"We welcome this independent inquiry."
MH Creutzfeldt-Jakob Syndrome/*transmission; Decontamination; England; Human; Risk Factors; Risk Management; *Surgical Instruments
SP englisch
PO England