A couple of outbreaks of Clostridium difficile at the hospital resulted in 33 deaths far more than the 12 originally thought. Health Secretary Patricia Hewitt had ordered an investigation into the incident. "At Stoke Mandeville, the leadership of the trust compromised the safety of patients by failing to make the right decisions, even though they had the benefit of experience from the first outbreak. They rejected the proper advice of their own experts," said Anna Walker, chief executive of the Healthcare Commission.
"We fully recognise that these outbreaks are not easy to control. But we also know that trusts can minimise the spread of infection so long as they follow established advice on infection control." The chief executive of the Buckinghamshire Hospitals NHS Trust left his position after the outbreak became beyond control.
The report has indicted senior managers for failing to listen to advice from infection control staff, clinicians, nurses, and the Health Protection Agency even when the outbreak was at its peak. The report said managers were more interested in finance control and in meeting government targets.
The report recommends that the hospital must review criteria for transferring patients between wards and ensure that wards are properly cleaned and infection control is prioritised. The hospital has 60 days to implement these measures.
"We are determined to learn everything we can from the report, and fully accept the Healthcare Commission's recommendations that the outbreaks should have been handled better, and that there are organisational issues on which work is needed," said Alan Bedford, the newly appointed acting chief executive of the trust. "Our priority is to work with staff on the issues raised by the report and to reassure patients that they are in safe hands."