David Raleigh
The nature of the findings of a report, which concluded a hospital superbug “may have” contributed to eight patient deaths, were described by one of the report’s main authors as “woolly” and “not definitive”.
The report published today by UL Hospitals Group concluded that CPE (Carbapenemase Producing Enterobacteriaceae) may have been an associative factor with the deaths of eight patients.
The report is the culmination of findings from an internal review by UHL as well as an independent external review carried out by UK Consultant microbiologist Dr Robert Spencer.
It found CPE detections in 196 patients between February 2009 to May 2017 out of which 73 patients had died.
The majority of patients who tested positive for CPE were colonised by (harmlessly carrying) the bug, rather than being infected.
The external review was ordered in October 2017 after UHL received notification that a whistleblower had made a protected disclosure to the Limerick City Coroner “alleging 36-CPE positive patients had died as a result of wrongdoing by UL Hospitals Group in failing to control the spread of the bug”.
The final report concluded that while CPE may have been associated with the deaths of eight patients, all eight had “significant underlying (medical) problems”.
Despite UHL and Dr Spencer initially offering contradictory narratives in their reports, a consensus was eventually reached and a final report agreed.
Dr Spencer’s external review had initially “found five cases in which CPE may have been a contributory factor in their death”.
However, UHL’s review initially found “three cases where CPE was found to have contributed directly to the death of a patient and a further 10 in which CPE-acquisition may have planted an associative role”.
Prof Paul Burke, UHL Hospitals Group Clinical Director, said: “Differing opinions will always exist between clinicians as to the relative contributions of different conditions to a patient’s death in those who suffer from multiple medical problems.”
“We believe our conclusions are reasonable,” he added.
Speaking at a press conference at UHL, Dr Spencer said, all of the cases examined had “a very complex medical history”.
He said he found it “extremely difficult” to “tease out” the actual cause of death.
Earlier Dr Spencer described elements from his own report, regarding trying to determine the cause of death of a patient with underlying co-morbidity factors, as “woolly” and “not definitive”.
[quote]It’s very very difficult to say which is the cause of death. That's why, in my report, I talk about ‘an association’ or ‘a contribution’ to death, and that’s why I suppose you could say it’s somewhat woolly; it’s not definitive.[/quote]
When asked later to clarify whether he was referring to the actual findings of the report or the possible cause of death of the patients, he replied: “Both in actual fact.”
The families of the eight patients have been offered face-to-face meetings with UHL management. Two have declined and the hospital is still trying to contact the last family.
UL Hospitals Group CEO, Prof Colette Cowan said UHL has “worked vigorously” and “invested heavily” to improve screening and surveillance systems, and there has been no CPE blood-borne infection at UL Hospitals since June 2015.
She praised the UHL microbiology team and described as “ground-breaking” their discovery of the first-ever CPE case in the country, at UHL, in 2009.
Professor Martin Cormican, National Clinical Lead on Anti-Microbial Resistance and Healthcare Associated Infections, said UHL is “as a safe as any other hospital”.
He said CPE has already been declared “a national emergency” by the government who are committed to supporting measures to try to curb it spreading.
“CPE is a global problem” with outbreaks across the world, said Corsican.
