An investigation into the outbreak of a bacterial infection that killed 15 people has found there were several “missed opportunities” in their care.
Mid Essex Clinical Commissioning Group has released the outcome of a 10-month investigation into a Strep A outbreak in 2019, which killed 15 people and affected a further 24. The final report was critical of Provide, a community interest company based in Colchester, as well as the former Mid Essex Hospital Services Trust (now part of Mid and South Essex Foundation Trust).
It said: “This investigation has identified that in some cases there were missed opportunities where treatment should have been more proactive, holistic and timely. These do not definitively indicate that their outcomes would have been different.”
Investigators found that 13 of the 15 people that died had received poor wound care from Provide CIC. They reported that inappropriate wound dressings were used and record keeping was so poor that deterioration of wounds was not recognised.
Even wounds that had not improved over 22 days were not escalated to senior team members for help or referred to the tissue viability service for specialist advice, with investigators told this was often due to concerns over team capacity.
The report, commissioned by the CCG and conducted by consultancy firm Facere Melius, said: “[Some] individuals became increasingly unwell over a period of time in the community, yet their deterioration either went unnoticed or was not acted upon promptly. Sometimes their condition had become so serious that they were very ill before acute medical intervention was sought”.
Other findings included delays in the community in the taking of wound swabs to determine if the wound was infected and by which bacteria. It said in one case nine days elapsed before the requested swab took place. Even after Public Health England asked for all wounds to be swabbed following the initial outbreak, this was only conducted on a single patient.
In other cases there were delays in patients being given antibiotics and this “could have had an adverse impact on the treatment for infection”.
It also found that sepsis guidelines were not accurately followed, wounds were not uncovered for inspection in A&E, and some patients were given penicillin-based antibiotics despite penicillin allergies being listed in their health records.
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Source: HSJ, 17 September 2020