31st July 2008

The Healthcare Commission report described a litany of errors in infection control that caused an avoidable tragedy. 90 patients died as a direct result of serious lapses in hygiene which Health Secretary Alan Johnson called scandalous. In addition to these deaths the Commission identified a further 179 patients whose deaths were at least partly caused by the errors in infection control.

The report into the Maidstone and Tunbridge Wells NHS Trust found that poor staffing, dirty wards and too much focus on financial management all contributed to two serious outbreaks of C diff in 2005 and early 2006.

In spite of this the police have decided that nobody will be charged! Following their review of the Commission’s report they have concluded that because in their opinion there is no chance of a successful prosecution they will not conduct a criminal investigation into the Trust. In a statement, Kent Police said “Having reviewed the report and interviewed the author and the experts engaged by the Healthcare Commission, Kent Police has concluded that there is no information to indicate that any grossly negligent act has occurred.”

The Health and Safety Executive (HSE) have also decided that there is insufficient information to prove that offences under health and safety legislation occurred and so are also dropping the case. Sandra Caldwell, its deputy chief executive, said “HSE shares the police’s conclusion that, from the information available, we cannot establish with certainty a causal link between failings to manage infection and the death of any particular person”.

Anna Walker, chief executive of the Healthcare Commission, said the trust was so focused on meeting Government targets and dealing with high levels of debt that it failed to deal properly with the infection risk. Nurses at the trust were too rushed to wash hands and left patients to lie in their own excrement. Alcohol wipes, which do not kill C diff, were used to clean toilets rather than soap and water, which does. Bedpans that had been washed still contained visible traces of faeces. Beds were much too close together and patients with infection were being treated on open wards instead of in isolation.

Geoff Martin of campaign group Health Emergency said the outbreak was possibly the worst single, corporate failure in the history of the NHS. He said: "The decision not to bring charges over the catastrophic management failures at Maidstone and Tunbridge Wells sends out a signal that no matter how many people die, those at the top can bail out without taking the rap”.

The Chief Executive of the NHS, David Nicholson, said that the Trust’s failures were wholly unacceptable.

That the police concluded that it did not have a duty to prosecute and so has failed to carry out a proper criminal investigation is surprising. They state that they considered charges of corporate manslaughter or gross negligent manslaughter committed by an individual, but their investigation concluded there was no information in the commission's report to suggest any death referred to amounted to manslaughter.

We believe that the public interest has not been well served. Public confidence in the police force will not be improved by their failure to fully investigate these deaths, however, at least those in authority in health trusts around the country can sleep easier in their beds tonight in spite of deaths from C diff rising by over 70% last year.