Friday, 26 October 2012

Systematic Failings Ruling Over Aspergillosis Case

A recent coroners court case found that a 68 year old man died following a lack of precautions taken to protect him from infections including aspergillosis. Extra precautions are not usually necessary following a bowel operation such as that undertaken on Mr Michael Meek in January 2009, but in this case there were several extenuating circumstances:

  1. the  patient had had a transplant operation prior to the bowel operation and as such was presumably in an immunosuppressed state as is normal to prevent rejection of the transplanted organ (in this case a kidney).
  2. At the time of the operation there had been, or there were ongoing building works in the hospital, generating dust and dirt known to increase the risk from aspergillosis
  3. Mr Meek was moved into wards where no protection was in place to prevent infection without consultation with the hospital infection prevention team
  4. Mr Meek was housed in a ward where other patients were suffering from C. difficile infection, known to be infectious and especially so in this case due to Mr Meek's reduced immune status
The coronor ruled that these amounted to systematic failures that led to the death of Mr Meek while suffering  from invasive aspergillosis (which caused severely debilitating injury) and C. difficile infection.

If any one of these circumstances had been different Mr Meek may have been less likely to have become infected. This case illustrates how carefully hospitals must manage buildings work and the identification of individuals vulnerable to infection, particularly where aspergillosis is a risk for the patient.

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