Report reveals superbug was ‘associative factor‘ in eight patient deaths at UHL

Prof Colette Cowan, Prof Paul Burke, Dr Robert Spencer and Prof Martin Cormican speaking at the press conference Picture: Press 22

Prof Colette Cowan, Prof Paul Burke, Dr Robert Spencer and Prof Martin Cormican speaking at the press conference Picture: Press 22

AN INTENSIVE year-long investigation into 73 patient deaths in Limerick and Mid-West found that the CPE superbug was an associative factor in eight deaths.

The findings have been published this Tuesday morning in a 60-page review detailing the results of internal and external examinations which analysed medical records belonging to 73 patients who died between February 2009 and May 2017.

The report states that, while CPE may have been a factor in eight years, “no patient died directly from CPE” and all eight patients had “significant underlying health problems”.

In September, the Limerick Leader received leaked official documentation confirming that CPE may have been “an associative factor” in seven deaths.

The investigations were conducted on foot of whistleblower allegations that 36 patients died as a result of the superbug, which has been robustly repudiated by the UL Hospitals Group for nearly two years.

Of the main findings, the report said that there were “some shortcomings” in the documentation and communication to patients and their next-of-kin of superbug status. Shortcomings were also identified in notifications to the coroner around the status of the deceased patients.

“Both these matters are being improved upon,” a spokesperson for the UL Hospitals Group said.

An independent internal review found that CPE contributed directly to three deaths, and that it may have been a contributory factor in a further 10 deaths.

The external review, conducted by UK microbiologist Dr Robert C Spencer, found five cases in which the superbug may have been a contributory factor in their deaths. All five “had serious underlying clinical conditions and comorbidity factors”.

A supplementary report was requested by Prof Paul Burke, the chief clinical director of the UL Hospitals Group, in order to reconcile both review findings. In this report, received in December 2017, it stated that CPE may have played an associative role in eight deaths but “deaths arose directly” from the superbug.

CPE—carbapenemase producing enterobacteriaceae—are multi-drug resistant bacteria carried in the gut. The superbug has, over time, developed the power to be resistant to the most powerful of last-resort antibiotics, proving to be an adverse challenge to acute hospital settings and to human health.

Of the 73 cases reviewed, the majority of which were colonisation or carriers of CPE. This means that the superbug was resting harmlessly in the gut.

There is generally a 50% mortality for those with skin or bloodstream infections.

There has not been a bloodstream infection since June 2015, the spokesperson confirmed.

The first ever case was detected at University Hospital Limerick in 2009.

Highly critical Hiqa (Health Information and Quality Authority) reports have led to widespread political and media attention since 2014.

A spokesperson for the UL Hospitals Group said that all next-of-kin have been informed of the findings. The results of the reviews have also been communicated to coroner John McNamara, the HSE, the Department of Health and Hiqa.

Commenting on the findings, Prof Burke said CPE was only “one of a number of factors contributing to their deaths”.

“Differing opinions will always exist between clinicians as to the relative contributions of different conditions to a patient’s death in those who suffer from multiple medical problems. We believe our conclusions are reasonable,” he said.

A total of 196 CPE detections have been recorded by the microbiology unit at UHL since 2009, though this does not mean the superbug was acquired at UHL.

Since the launch of the review in June 2017, more than 41,000 CPE screens were carried by the group.

Prof Colette Cowan, CEO, UL Hospitals Group, said: “We are conscious in publishing the review today that behind every number, there is a family who has lost a loved one. We know that in revisiting these matters, we may be adding to their distress. We apologise for this but we felt strongly that all next-of-kin should be informed of the review findings.”

“CPE is not an easy thing for people to come to terms with. We would like to reassure patients and to reassure the public that the precautions we take in screening for CPE and in cohorting or isolating CPE contacts or CPE-positive patients are taken to minimise the risks to the most vulnerable patients.

“We hope that in publishing the report today - together with national initiatives such as the CPE Contacts Communications Programme and the declaration of a national public health emergency by the Minister for Health – we can contribute to a better informed public conversation around multi-drug resistant organisms and the real risks they pose to public health,” Prof Cowan added.

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