Babies in the Royal Jubilee Unit in Belfast were being washed in contaminated tap water even after a deadly pseudomonas outbreak at the hospital, a damning report has revealed.
The independent report by the Regulation and Quality Improvement Authority (RQIA) into the deaths of four babies from the deadly infection uncovered a litany of failures of communication between health officials in Northern Ireland.
An Assembly committee heard on Wednesday that some of the babies who died from the pseudomonas outbreak could have survived if the Belfast Health Trust had acted more quickly.
Three babies died in the Royal Jubilee Maternity Unit in January, while another newborn died at Londonderry's Altnagelvin Hospital in December from the infection which is usually found in stagnant water.
The RQIA report also concluded that the neonatal unit in Belfast should be urgently replaced to improve infection control.
Health Minister Edwin Poots was on Thursday set to hold a crunch meeting with the Belfast Trust’s chief executive Colm Donaghy and chairman Pat McCartan following the highly critical interim report.
On Wednesday, Mr Poots met with the families of the four babies who died. He later told the Stormont health committee: “That’s not an experience I want ever to have to do again.” But he said he had been “overwhelmed” by the dignity of the parents.
Speaking following the meeting, Gavin Burke, father of baby Caolan Campbell who died at Londonderry's Altnagelvin Hospital, said he hoped lessons had been learnt because he “didn't want this to happen to another family” in the future.
The independent review team, led by Professor Pat Troop, found there was a lack of communication between staff in health trusts during the outbreak. They said this lack of structure and co-ordination may have impacted on how decisions were made.
After the fatality at Altnagelvin last year, chief medical officer Dr Michael McBride sent a circular to all trusts on December 22. It urged infection control teams to assess risks but did not specifically mention pseudomonas at Altnagelvin or the death of a baby.
Professor Troop said: “We have had some information on what they did but not enough. I cannot really say how much difference it would have made until we have gotten down to the detail.”
Turning to the outbreak at the Royal, she said: “When the unit (in Belfast) thought that they may have an outbreak, they stepped up their infection control but they did not test the water and they did not introduce sterile water for cleaning the babies.
“Had they done that, it might have improved the situation somewhat earlier.”
Her report found that the outbreaks of infection of pseudomonas aeruginosa, which occurred in the neonatal units at Altnagelvin and Royal Jubilee Maternity Hospitals, were linked to contaminated tap water.
The Assembly committee heard hospital staff should have known the most likely source of the infection was tap water and should have been using sterile water more quickly.
The Health Minister said on Wednesday he was “far from satisfied” with the actions of the Belfast Health Trust during the crisis.
Mr Poots said while the Western Health Trust implemented the use of sterile water quickly, the Belfast Trust failed to follow suit “until quite a number of babies were infected”.
“I am far from satisfied that they responded quickly enough,” he told Stormont’s health committee.
Committee chairperson Sue Ramsey, of Sinn Fein, said it was “quite an explosive” report which would probably add to the grief of the parents who lost their newborn children.
At the committee hearing, the DUP’s Jim Wells directly asked Professor Troop if some of the babies would have survived if the Belfast Royal Maternity had “acted differently”.
Professor Troop replied: “It’s possible.”
Mr Wells said it seemed it should have been obvious “from the word go” that the likely source of the infection was water taps.
Professor Troop said there was a stage when staff at the Royal could have taken more action — including using sterile water — but had not done so.
Mr Wells asked: “Was that a major mistake?”
Professor Troop said: “In retrospect, they should have done that.”
Mr Poots said he was not going to be involved in any “cover up or sham” and intended to implement the 15 recommendations of the report by the panel, which is continuing its investigation and will publish a final report.
“We have to have the honesty to say to the public ‘we got it wrong’,” the DUP minister went on.
Mr Poots said a specialist team met in Belfast, following the Altnagelvin death just before Christmas, and was not intending to meet again to discuss the implications until January 24. The minister said he would have expected to see more immediate action.
The report also recommended the neonatal unit at the Royal be replaced to improve infection control. The unit does not allow enough space around each cot and there is a lack of appropriate accommodation for isolation or cleaning equipment in the regional neonatal intensive care centre, the report found.
Mr Poots said on Wednesday that it is scheduled to take four years before a new maternity hospital at the Royal is introduced.
The pseudomonas outbreak cost the lives of four newborn babies in Northern Ireland - three in the Royal Jubilee Maternity Unit in January and one in Altnagelvin Hospital. The source of the infection was confirmed as tap water a few days after the fourth baby died. Health Minister Edwin Poots commissioned an investigation, the results of which landed on his desk last Friday. Since the outbreak all 175 taps in Northern Ireland's neonatal units are being replaced, with priority being given to taps where contamination had been detected. Neonatal wards have also conducted deep cleans and checks for the bacteria.