01 November 2002
The chief medical officer for England has ordered an inquiry into the errors that led to 24 patients in Middlesbrough on Teesside being exposed to Creutzfeldt-Jakob Disease.
Sir Liam Donaldson ordered the investigation this week amid fears that the NHS has relaxed its approach to the prevention of CJD transmission.
'I have asked the regional director of public health, Dr Bill Kirkup, to fully assess the facts and report to me shortly. His report will ensure that any measures necessary to improve local procedures or strengthen national policy are taken,' he said.
'No-one should rush to judgement on this case. Dr Kirkup's report will establish the full facts and I will then make whatever recommendations are necessary to ministers.'
He added that the trust's sterilisation methods had been assessed as acceptable last year.
Earlier, the Department of Health had described the incident at South Tees NHS Trust as 'appalling'. The patients at Middlesbrough General Hospital had been operated on with instruments that had been used to perform a brain biopsy on a woman who was later found to be infected with 'sporadic' CJD. Patients are being contacted and a helpline set up.
The trust insisted the likelihood of infection was very low. Only five cases of transmission via surgical instruments have been confirmed worldwide. It added that it had followed the department's guidelines, which were laid down in August 1999.
South Tees NHS Trust director Dr Paul Lawler said: 'It's possible it could happen again tomorrow in this hospital or in any other hospital.'
It appears confusion arose because of a grey area in the guidelines. The trust did not quarantine the instruments until after the diagnosis of CJD had been confirmed, even though the department's guidelines say quarantine must be observed if CJD is suspected.
However, in this case there was no suspicion that the patient was infected with the disease until after her death.
PFnov2002
