ISO 13485 | Medical Devices Quality Management | MD 69713
They had BOTH died as a result of sepsis caused by the Herpes virus soon after giving birth. They were BOTH assumed to have bacterial infections and treated incorrectly as the Herpes virus is a viral infection, and so should have been treated with anti-viral medication.
I was an NHS Scrub Nurse between 2010 and 2018 and infection control was key to the job, it was everyone’s responsibility to maintain a sterile environment and prevent cross contamination in the operating theatre.
Herpes Virus is transmitted by “Brief skin-to-skin contact” according to The World Health Organisation (WHO 2020). In this time of Personal Protective Equipment, there is no excuse to pass on any infection skin to skin as the surgeon would be completely covered, or so you would expect.
I have seen surgeons lapse in their standards by not wearing face masks etc and been met with defiance when I have pulled them up on it. I can understand if a tear in a glove could cause one contamination, but two seems beyond likely probability.
The BBC explain both sets of families were informed there was no link to their deaths, yet to an onlooker, there must have been. Surely the connection was there for all staff to see ? The same hospital, the same surgeon. Immediate alarm bells are ringing for me.
So why did it take the BBC investigation to unearth the facts?
The NHS state that “It is important we are transparent in all the work we do”
So what happened in this case ?
Documents were discovered by the BBC that clearly showed that the trust were informed two weeks after the second death from the surgical contamination, yet the trust failed to inform the Coroner’s office of these circumstances surrounding the two deaths.
The NHS trusts are given huge fines of around £1 million by the Care Quality Commission (CQC) when a death occurs, could this be a factor? Accountability to the patient is always correct, but there is an argument for the individual doctor to be accountable, for malpractice.
The NHS are so stretched, and each individual trust has to work within their budget, so a fine like this will be detrimental to the care of all who attend the hospital. Does that excuse the non-disclosure ? No, it doesn’t. But if a surgeon is carrying out invasive procedures and caused death through negligence in whatever fashion, then the surgeon should be solely accountable.
Why are the surgeons not covered by their own Public Liability Insurance ?
Well, they are covered and here is where it gets tricky. The hospital trust will receive indemnity through the Clinical Negligence Scheme, so who pays for that ? The taxpayer. So, in essence we the hospital users, pay the surgeons fine, and the NHS trust struggles on with less budget because of one person’s actions.
An idea for reform is to make it mandatory for all doctors and surgeons whether NHS or Private, to have more Insurance and stop penalising the NHS. Then the hospital trust may just have a few extra £s in the pot to do what they really need to do, and be transparent at all times, not just when they get caught out by investigative journalism.
What do you think? Email: Nursing@upccambridge.co.uk
Read the full story here. https://www.bbc.co.uk/news/health-59382447