STRONGER communication between medics and families needs to be established, a report into the pseudomonas outbreak in the North – which claimed the lives of four babies in two hospitals – has found.
The first victim of the pseudomonas aeruginosa bacterium died at Altnagelvin Hospital in Derry last December. Three more babies died at Belfast’s Royal Jubilee Maternity unit in January.
The final report by the independent Regulation and Quality Improvement Authority (RQIA) found that “formal communications networks” were needed to “ensure that information is not lost and reaches those that need it in a timely manner”.
It also confirmed contaminated water taps as the most likely source of infection in the neonatal units – something suggested in a previous interim report presented by the authority.
Minister for Health Edwin Poots said he would act upon all the recommendations put forward, including that each of the North’s five trusts establish a dedicated communications plan for such incidents, including arrangements for engaging with families.
Referring to the bereaved families, Mr Poots said: “Words are never enough. Nonetheless I want to once again say how sorry I am for what they have suffered . . . Actions speak louder than words and the most meaningful expression of sympathy is to take effective and swift action.”
It was crucial for changes to be enforced quickly, he continued.
“When I commissioned this review, my intention was to ensure that whatever lessons needed to be learned would be identified immediately . . . That is why I set a demanding timescale.”
Led by Prof Pat Troop, a former chief executive of the Health Protection Agency, the final report concluded that “in serious events, communication is often one of the casualties”.
Communication efficacy was not uniform, with “examples of excellent communication, but also of situations where important information was not communicated effectively”.
In all, the report made 17 recommendations to Mr Poots, on top of the 15 recommendations already made in an interim report, presented by the authority in March.
In considering the experiences of the families, the report concluded that lack of information and speedy communication had, in some cases, added to their grief.
Parents reported feeling “overwhelmed” by the complex language used by senior medics and told the review team that doctors did not feel they could always explain what was going on, due to “confidentiality”.
While, in general, families were “satisfied with the standard of care provided for their babies”, they felt that “communication, in particular the level of language and information regarding the seriousness of the pseudomonas colonisation/ infection, could in some cases have been improved”.
The interim and final reports focused on different aspects of the incident. The interim report suggested the babies’ deaths might have been prevented had health officials acted sooner.
Among its recommendations was that sterile water be used for washing babies in neonatal units.
According to the Department of Health, Social Services and Public Safety, this has since been implemented.