HSE admits ‘catastrophic failure’ over contamination mix-up

Hospital investigating how 18 families wrongly told children may have been contaminated

Crumlin Children’s Hospital apologised to 18 families wrongly identified in a contamination scare.

Crumlin Children’s Hospital apologised to 18 families wrongly identified in a contamination scare.

Thu, Jul 25, 2013, 20:25

Our Lady’s Children’s Hospital in Crumlin, Dublin, is investigating how 18 families were wrongly told their children may have been contaminated by a medical instrument.

The hospital this morning apologised to the families and said seven separate patients were now being contacted about the colonoscope contamination.

The head of the HSE has said the incident represented a “catastrophic failure”. Addressing the Oireachtas committee on health this morning, Tony O’Brien said: “No amount of spinning by public relations companies can mask the seriousness of the issue”.

He said he had established an immediate review into how the issue occurred.

Minister for Health James Reilly said there was a major communication issue at Crumlin and many people had been caused upset unnecessarily. He said he was very sorry about that.

“ I think we have learn from this and make sure these sort of avoidable errors never happen again,” he said. The Minister said patient safety had to be the primary concern. “To err is human but we have to build a system that where human error occurs the system protects the patient from it.”

Dr Colm Costigan, clinical director of the three Dublin paediatric hospitals, said the mix up involved two coloscopes—medical instruments used in bowel examinations—that failed hospital tests on July 6th.

One of the two scopes was contaminated with ESBL. ESBL or extended spectrum beta lactamases are bugs that live in the bowel. They are produced by bacteria to combat antibiotics. They break down the commoner antibiotics and can make infections more difficult to treat.

The contamination was incorrectly attributed to the second scope, leading the hospital to believe 18 children treated with it may have become infected.

Dr Costigan said he contacted the 18 families yesterday to explain the situation to them. He also told RTÉ’s Morning Ireland that he had gotten in touch with six of the seven new families and was still trying to reach the remaining family.

He apologised for the mix-up, adding “we have to have a proper look back to see the proper reasons for that mistake. There’s a formal investigation going to take place with the National Incident Management Policy with the hospital and the HSE.

The hospital intends to test the seven children to see if they carry the bacteria. “The important point here,” Dr Costigan said, “is that the families or the person would know that they carried ESBL so if the child was very ill or in hospital with an infection the doctors would choose the correct first line antibiotics so that there’d be no time wasted in dealing with the infection.”

Following the initial scare, a spokeswoman for the hospital said, “if any child is found to be positive, the hospital will arrange to meet the family and will provide them with all the necessary information and support.”

A positive screen “has no immediate impact” for patients, she added, but it may affect the first line antibiotics chosen to treat the child if they show signs of infection.