Thursday 17 September, NHS Mid Essex Clinical Commissioning Group
(CCG) is publishing the independent investigation report it commissioned under the
NHS England and NHS Improvement Serious Incident Framework last year. The
report addresses an outbreak of invasive Group A Streptococcus (iGAS) in mid and
west Essex between February 2019 and August 2019.
In a thorough and detailed review lasting more than six months, independent
investigators spoke to the families of patients who had sadly died after contracting
the infection. They met healthcare staff and clinical leaders who had been
responsible for the care those patients had received.
The investigation team also reviewed more than 1,700 documents in relation to the
incident management of the outbreak. The report compiled from the investigation
explains where improvements can be made to reduce the risk of a similar outbreak
happening in the future.
Rachel Hearn, Director of Nursing and Quality for the Mid and South Essex CCGs
Acute Commissioning Team and NHS Mid Essex CCG’s Director of Nursing, said:
“I would like to express our deepest sympathies to the families of those patients who
passed away. We thank them for contributing to the investigation at such a difficult
time.
“The safety and care of our patients is our priority. We commissioned this
independent investigation to ensure that we could understand areas for improvement
and take prompt action to reduce the risk of a similar outbreak happening again. The
report details a number of recommendations and we have taken swift action along
with our partners to ensure changes have been made quickly and safely.”
The independent investigation team could not identify a single source of
transmission of the iGAS outbreak. While the strain of Group A Streptococcus
involved was isolated to a small number of clinical workers, the spread was likely to
have occurred in a number of ways with no direct link to any individual. There have
been no new cases of iGAS in mid-Essex since August 2019.
The report recognises good practices during the outbreak but also identifies areas
requiring attention and missed opportunities for more proactive treatment. It makes
22 recommendations to the organisations involved, covering the areas of:
• Wound management
• Identifying clinical deterioration
• Antibiotic therapy
• Infection prevention and control
• Record keeping
More than a third of recommendations have been fully implemented across the CCG,
Provide Community Interest Company and Mid and South Essex NHS Foundation
Trust. All remaining recommendations are in progress and are on track to be
completed, to schedule, by the end of the year.
Stephanie Dawe is Chief Nurse and Chief Operating Officer at Provide Community
Interest Company, which received the most recommendations. Stephanie said:
“We were deeply saddened by the deaths of a number of people from this dreadful
infection. It’s impossible to understand the loss their friends and family feel but we
want to offer our sincere condolences.
“We may never fully understand the route of transmission but there are clearly things
we need to do differently. The report highlights a number of areas for improvement
and our nursing teams have been working diligently to make these changes.
“The healthcare system found this outbreak an extraordinary challenge and there
was much learning taking place for our teams and our organisation. We consistently
strive to do our best by the people we serve and remain conscious that our nurses
worked extremely hard to contain the infection.”
Immediate steps were taken when the outbreak was identified to reduce the
likelihood of it happening again, such as reducing the number of different staff in
contact with an individual patient and deep cleans of clinical areas. Work continues
to embed the remaining recommendations, with each action undergoing a robust
review and evidence process before being signed off as complete.
Dr Kevin Beaton, Medical Director for Mid Essex Hospitals, part of the Mid and South
Essex NHS Foundation Trust, said:
“We have worked very closely with our colleagues across the health system to
ensure that we have learned all the lessons that we can from this outbreak.
“Our absolute priority is that our patients receive the best possible care and the
report has been helpful in confirming our areas of focus.
“We have a detailed action plan in place and have already made a raft of
improvements including implementing comprehensive programmes of training and
audits, and standardising policies and procedures across all of our services.”
The investigation report will be available from the CCG website at
midessexccg.nhs.uk/about-us/our-key-documents/3893-independent-investigationreport-igas
