The news that Gardai in Waterford have sent a file to the Director of Public Prosecutions, arising from an investigation of a complaint by a local doctor whose husband died after contracting MRSA, apparently at the city’s regional hospital, is sure to raise questions about whether the MRSA risk management strategies go far enough.
We may not know for some time whether the DPP will bring criminal charges in the case and, if he does, whether a successful prosecution will give momentum to the strategy, or force health authorities to develop a more ambitious one. The fact that a file is sent to the DPP doesn’t mean that a prosecution is imminent or will even take place. Even if it does, the derisory penalties open to the courts under the Health Act of 1947, which contains the legislative provision under which this complaint is being investigated, mean that the case, on its own, is unlikely to make much difference.
Against the background of last week’s verdict from a coroner’s court in Cork, where the finding was of death by MRSA, a successful criminal prosecution in this instance would put various civil cases pending, with potentially significant damages,in a new light.
Heart of the matter
At the heart of the matter is a legitimate expectation that patients should not be left worse off by people and places that are supposed to make them better. Under the 1947 Act, there is a general duty to take precautions to prevent people getting an infectious disease.
Section 30 obliges any person who knows they are a probable source of an infection to take every reasonable precaution to prevent it passing to someone else “by their presence or conduct or by means of any article with which … [they have] … been in contact.” It further obliges those who are caring for others whom they know to be a probable source of infection, to take every reasonable precaution to prevent those people infecting someone else.
However, there appears to be no provision for anything other than a summary conviction, which carries a fine of just over €60. Hence the very real possibility that this case, on its own, if it comes before the courts, would not set our health services on a radically different path.
MRSA bloodstream infections have been a serious problem in our hospitals for many years. In 2005, there were just under 600 cases reported. It’s now thought that at least 100 people are taking civil cases against hospitals, which they believe are responsible for their infection.
The HSE’s strategy of risk management, which international experts acknowledge should prevent the problem from getting much worse, offers no guarantee that it will get much better anytime soon. Yet the experience of some countries in Europe, particularly Holland, is that time, money and commitment can make all the difference.
Holland has been almost uniquely successful in tackling MRSA, which now accounts for just one per cent of this infection type in hospitals there, compared to an estimated incidence of 42 per cent in Ireland.
The Dutch operate a simple but highly effective “search and destroy” policy, which utilises systematic screening; a combination of lower bed occupancy rates and higher bed numbers; and better hospital cleaning practices to prevent MRSA from getting a foothold as a normal, everyday hospital infection in the first place. The belief is that, if MRSA can be controlled in hospitals, there is less of a chance of it spilling out widely into the community, where it would be much harder to eradicate.
Anyone regarded as a high risk is isolated for up to five days when they enter a hospital to ensure they can’t infect other people. Staff with MRSA on their skin are sent straight for treatment and go off work right away. And any ICU that is hit by an outbreak is closed down fast.
The Health Service Executive (HSE) says capacity and historical issues mean we can’t follow that lead. But the question raised by pending civil actions is not whether old constraints prevent more from being done, but what new measures may have to be taken now or very soon because the courts say so.
We should be aiming at a minimum to ensure that new hospital building projects include permanent isolation facilities, and that older hospitals are retrofitted with suitable pre-fabricated isolation buildings.
Infection Control Teams need to be rolled out fully and given full power to isolate patients and visitors, to close down and order the cleaning of high-risk areas, and to screen and withdraw healthcare staff as a matter of routine and policy whenever this is necessary.
Calls by the MRSA and Families Network for a judicial inquiry and redress board need to be seen in the context of a desire by those affected to exact accountability, responsibility and compensation for wrongs done as a result of avoidable failings in patient care and safety standards.
There is a danger, however, that any more than well-intentioned legislation that could be enacted easily, but which would lack credibility because it isn’t at the centre of a web of systematic screening and isolation, collective learning, individual responsibility, adequate inspection and rigorous enforcement.
We need to reckon in the significant costs that the inquiry/redress route would create. I do not mean the resources required to compensate those entitled to redress, but, rather, the reality that the process itself will be costly, complex and protracted. The inevitable delays and arguments may cause funders and providers to turn their backs on making a significant financial and cultural commitment to addressing current problems because of a belief that any part of the outcome would be to turn back the clock on past mistakes.
It’s vital to challenge and change custom and culture and to back these changes with funding and practices that support screening, isolation and treatment; the creation of clear, enforceable protocols from current guidelines; and an evidence trail from hospitals to nursing homes.
In doing this, the goal should not be to facilitate people in avoiding or evading responsibility and accountability, but to ensure that the highest standards of safety and care are an every-day reality for all patients.