Review of fatal Essex Strep A outbreak identifies failings in care

The report was commissioned last year to investigate the outbreak of invasive Group A Streptococcus (IGAS) in the mid and west of Essex between February and August in 2019.

A total of 15 people died as a result of the outbreak but the report only takes into account 13 of them due to administrative issues – one in Colchester Hospital and 12 in Broomfield Hospital in Chelmsford.

The bacteria can cause many different infections ranging from minor illnesses to deadly diseases.

What did the report find?

One person died in Colchester Hospital, 12 in Broomfield Hospital, one in Basildon and one in Southend. Picture: HOLLY HUME (Image: Archant)

The report, published on Thursday September 17, found ineffective communication, delays in care, difficulties with patients following medical advice, serious incidents of drug errors and the cases of patients self-administering drugs and medicines.

One of the issues found in the report was the management of wounds. It was found deterioration of wounds was not always noticed in a timely manner due to the team being small and short-staffed.

Swabs of wounds were not always taken when they could have been to identify a source of infection and inconsistencies were found within the nursing teams where some were not trained in certain procedures.

There were also issues with noticing the decline in patients’ health as there were too many staff members attending to each case – one patient had 32 healthcare workers provide care over three months and another had nine in their final month of care.

This was due to a heavy caseload of patients combined with staff shortages across the integrated care team.

The investigation was unable to identify a single source of transmission of the IGAS outbreak, however found it was spread on a piece of equipment within a small community nursing team. This finding has sometimes created an atmosphere of blame.

Of the 22 recommendations made in the report, five were concerning wound management, four regarding identifying clinical deterioration, one for antibiotic therapy, three for infection prevention and control.

Another two were made about record keeping and a further seven supplementary observations were made, including improvements in guidance given to staff.

More than a third of the recommendations have now been fully implemented, while the rest are on track to be completed by the end of 2020.

What was the reaction to the report?

Rachel Hearn, director of nursing and quality for the Mid and South Essex CCGs Acute Commissioning Team and NHS Mid Essex CCG’s director of nursing, said: “I would like to express our deepest sympathies to the families of those patients who passed away. We thank them for contributing to the investigation at such a difficult time.

“The safety and care of our patients is our priority. We commissioned this independent investigation to ensure that we could understand areas for improvement and take prompt action to reduce the risk of a similar outbreak happening again.

“The report details a number of recommendations and we have taken swift action along with our partners to ensure changes have been made quickly and safely.”

Stephanie Dawe is chief nurse and chief operating officer at Provide Community Interest Company, which received the most recommendations.

She said: “We were deeply saddened by the deaths of a number of people from this dreadful infection.

“It’s impossible to understand the loss their friends and family feel but we want to offer our sincere condolences.

“We may never fully understand the route of transmission but there are clearly things we need to do differently.

“The report highlights a number of areas for improvement and our nursing teams have been working diligently to make these changes.

“The healthcare system found this outbreak an extraordinary challenge and there was much learning taking place for our teams and our organisation.

“We consistently strive to do our best by the people we serve and remain conscious that our nurses worked extremely hard to contain the infection.”

Dr Kevin Beaton, medical director for Mid Essex Hospitals which is part of the Mid and South Essex NHS Foundation Trust, said: “We have worked very closely with our colleagues across the health system to ensure that we have learned all the lessons that we can from this outbreak.

“Our absolute priority is that our patients receive the best possible care and the report has been helpful in confirming our areas of focus.

“We have a detailed action plan in place and have already made a raft of improvements including implementing comprehensive programmes of training and audits, and standardising policies and procedures across all of our services.”