West Midlands patients suffering infection after flexible cystoscopies

A serious incident report has been produced by Dudley Group NHS Foundation Trust. This investigation reviews the care provided between the dates of January to July 2020 at Corbett Outpatient Centre in Stourbridge, West Midlands. The effects on patients include for following:

• Urosepsis
• Pseudomonas
• Urinary tract infections
• Discitis
• Orchidectomy

It was identified that up to 10th March 2020, a total of 36 patients were admitted with either proven pseudomonas urinary infection (or other associated infections) or with a suspected infection but negative microbiological cultures.

This translates to an infection risk of 3.28%

When all component parts of the decontamination process for the cystoscopies were swabbed, this allowed the management team to isolate pseudomonas in a small detachable valve/tap (identified as the y valve) component which is separately cleaned and attached to the flexible cystoscope immediately before a cystoscopy procedure.

No action was taken from the management meeting to undertake an environmental review.

A process of regular swabbing of components has confirmed negative bacterial growth since the 9th June 2020.

In total, 46 patients were involved in this serious incident, however only 28 patients have been reviewed in this investigation. These 28 patients have either experienced pseudomonas in the cultures taken, or have come to some harm as a result of this incident.

• Eight patients came to significant harm
• Two patients required orchidectomies
• Four patients developed sepsis
• One patient developed haematuria
• One patient developed an infection of the spinal discs as a result of infection

The Serious Incident Report (SIR) states 24 patients on the urology audit list have been identified as being subject to harm and have been written to as part of a duty of candour

Bob Coupland, Head of Medical Negligence, comments:

“We need to identify any potential clients that had a flexible cystoscopy at Corbett Outpatient Hospital between January and July 2020, in order to suitably advise them of their potential legal rights.”