Written Ministerial Statement

The content of this written ministerial statement is as received at the time from the Minister. It has not been subject to the official reporting (Hansard) process.

Department of Health, Social Services and Public Safety - Independent Review of Pseudomonas Aeruginosa Infection in Neonatal Units in Northern Ireland

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Published on Thursday 31 May, 2012

Mr Poots (The Minister of Health, Social Services and Public Safety): I wish to make a statement to the Assembly about the publication of the Final Report of the Independent Review of Incidents of Pseudomonas aeruginosa Infection in Neonatal Units in Northern Ireland.

On 4 April I made a written statement to the Assembly to advise members of the publication of the Interim Report of the Review. Yesterday I received the Final Report from Professor Patricia Troop who chaired the Review.

The Final Report focuses on the third and fourth Terms of Reference. These are: (3) to review the effectiveness of the governance arrangements across all five Health and Social Care Trusts with regard to the arrangements for the prevention and control of infection and all other relevant issues in the respective neonatal units, and (4) to review the effectiveness of the communication between the DHSSPS, the HSCB, the PHA and the five Health and Social Care Trusts in respect of all relevant information and communications on the pseudomonas bacterium.

The Final Report is being published today, 31 May, on the RQIA’s website: www.rqia.org.uk. The report is also being placed in the Assembly Library.

I am meeting the Committee for Health, Social Services and Public Safety today to discuss the Final Report. Professor Troop and three other members of the Review team are attending this meeting to present the report and to answer questions.

In commissioning this review my intention was to ensure that whatever lessons needed to be learned from these tragedies would be identified immediately, and to ensure that those lessons would be acted on as quickly as possible. I set a demanding timescale for the review. I asked for an interim report by the end of March and the final report by today, and Professor Troop and her team have achieved that.

They have had to work quickly and intensively since February, and they have done so with sensitivity to the families who have suffered, and without compromising the rigour of their investigation. I am grateful to Professor Troop and her team for the way in which they have approached and completed this work.

I accepted the 15 recommendations that were in the Interim Report and I have accepted all 17 recommendations that are in the Final Report. I set a demanding timetable for the implementation of the recommendations from the Interim Report, and I will ensure that these and the 17 new recommendations are delivered as speedily as possible.

In previous statements I have paid tribute to the staff who work in our neonatal units and I do so again today. They have been deeply affected by the deaths of these babies and by the grief and the worry of the families who have been touched by these incidents, and they will continue to do their utmost to minimise the risk of future infections.

Many families have suffered through the pseudomonas incidents. Four families lost their babies to this infection. Another baby died who had been infected with pseudomonas. Other families have had the distress of seeing their babies become infected or colonised. Many more families – those whose babies were in neonatal units and maternity units at that time, and families whose babies were due – have been through an anxious time.

A significant theme that has emerged in this phase of the Review is communications: communications between the organisations concerned, and communications with the parents.

Communications between organisations is a matter of improving systems and processes and we can ensure that these are tightened up.

The question of communicating effectively with the parents is not a new one and the first recommendation in the Final Report highlights the need for the Trusts to address these problems in a systematic and systemic way. Each Trust will have to produce a communications plan whereby clinical staff will have the support that they need in order to be able to focus on clinical matters, and other roles will be taken on by other staff.

I want to thank again the families who have contributed to the Review. That has taken courage on their part and we owe them a great debt. I have expressed my condolences to them in person and in public statements; I believe the most meaningful expression of sympathy is to take effective and swift action so that other families do not have to suffer as they have done.


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