Hospitals across the State should immediately begin regular monitoring of air and water quality to reduce the risk of patients contracting hospital-acquired infections, an independent expert said yesterday.
Prof David Coleman made the recommendation at the publication in Kilkenny of an independent inquiry's report into the death of a patient at Waterford Regional Hospital last April after she contracted Legionnaire's Disease in the hospital.
Prof Coleman, a microbiologist who chaired the inquiry, said there was no doubt that Mrs Ena Kiely (61), of Kilmacthomas, Co Waterford, acquired her infection in the hospital where the water system, particularly the hot water system, was found to be "heavily colonised" with the Legionella bacteria which causes the disease.
However, he said it was impossible to conclude whether she contracted it from a shower head in the en suite bathroom of her room or from a contaminated nebuliser she had been using.
Furthermore, it was impossible to see if the strain of Legionella was the same as that found in the water system, as post-mortem samples were not available. This was because the woman's body had been embalmed before it was decided, in consultation with the coroner, that a partial post-mortem should be carried out.
Prof Coleman stressed this was the first reported case of a death from Legionnaire's Disease acquired in an Irish hospital. However, it was more than likely there had been other cases which had never been diagnosed because hospitals did not routinely test for it in people with fever or pneumonia. He hoped his report would change this.
Members of Mrs Kiely's family were not present at the publication of the report but copies have been sent to them. The South Eastern Health Board, which runs the hospital, offered to meet them but to date they have not taken up that invitation, the board's chief executive, Mr Pat McLoughlin, said. He also said no financial settlement had been made, but the board was corresponding with the family's solicitors.
Yesterday's report stressed Mrs Kiely was very ill when admitted to the hospital on March 21st. She had a six-week history of gastro-intestinal symptoms. She was diagnosed with pneumonia on April 14th and on April 21st was diagnosed with Legionnaire's Disease. Because its incubation period is 2-10 days, there was no way she could have brought it into the hospital. She died on April 27th.
The independent investigation found the temperature of the hot water system was not sufficiently high to prevent the growth of Legionella bacteria and that the hospital had not undertaken a formal risk assessment of the control and prevention of the bacteria. It found responsibility for management of risks in relation to Legionella were divided among several hospital services, with poor communication between them.
In addition it said the National Disease Surveillance Centre had issued guidelines to all health boards on eliminating risks of Legionella in January and the hospital had just begun to implement them when Mrs Kiely was diagnosed. All hospitals should now ensure the guidelines were followed, it said, acknowledging they had "resource implications".
The report said that one day after the diagnosis the hospital set up an internal investigation committee, which took a number of measures to reduce the risk of other cases occurring. It increased the hot water temperature, disinfected shower heads, chlorinated the water and introduced single-use nebulisers.
Prof Coleman said there had been some criticism of the hospital for not going public immediately the case was diagnosed. It did not do so until after Mrs Kiely's death.
However, he said he believed this was the correct approach as its first responsibility was to take steps to reduce the risk to staff, patients and visitors to the hospital. The inquiry had established Mrs Kiely's case was an isolated one. He said the engineering firm which designed the water distribution system had recently re-examined it and found some toilets had been moved, leaving stagnant water in some pipes. There were no guidelines for builders in the State on how to reduce the risk of Legionnaire's and he believed they should be put in place. In addition there were no national standards for cleanliness in hospitals and he believed these should also be developed to reduce the risk of hospital-acquired infections. Mr McLoughlin said the health board was committed to implementing all recommendations in the report. It had already made progress on a number of them.
The risk of anyone now contracting the disease in the hospital had been reduced by 98 per cent, Prof Coleman said, but there was no way the risk could ever be eliminated completely.
The Department of Health said it is arranging for the report to be circulated to all health boards and will be asking them to ensure its recommendations are fully implemented.