Possibly fatal bacterial infections at Guy’s and St Thomas’s Trust could be being under investigated, a coroner has said after a patient’s death.
Assistant coroner Briony Ballard raised the alarm in a report published this week investigating the death of a patient in St Thomas’s Hospital in 2017, who was found to have C. diff.
The Clostridium difficile bacteria can cause serious bowel problems, and symptoms of diarrhea, dehydration and painful stomach cramps.
Thirty-seven-year-old David Williams had been admitted to the hospital for complex surgery, and died as a result of ‘unintended’ complications with the procedure.
He had been treated on a high-dependency unit, was transferred to a general ward, and then back again to the unit when his condition worsened.
In the report it said he had contracted c.diff on the general ward – but because he was on a high-dependency unit at the time it was discovered, conditions were not investigated on the general ward.
The Trust admitted that treatment Mr Williams received on the general ward was “deficient in delivering the fundamentals of care.”
“At Mr Williams’ inquest I was told that c.diff infection is a potentially fatal infection,” said Ms Ballard, explaining that if found, the infection triggers an investigation.
However, “if the patient has recently been transferred from another ward, the investigation does not extend to the conditions on the transferring ward,” she said.
“In this case it was the transferring ward where there were found to have been failings … about which the family had raised significant concerns at the time.
“Although I found at inquest that that the presence of c.diff was not relevant to how Mr Williams ultimately came by his death, I have residual concerns with the potential under investigation of c.diff cases within the Trust.”
The failures only came to light after a probe in September last year at the Coroner’s request. However, it was “limited” as it was carried out “significantly after the event.”
The Trust said it would be inappropriate to comment at this time on whether its processes for investigating the bacterial cases had been changed.
It also refused to say at this stage whether an investigation should have been carried out sooner on the general ward after concerns were raised by Mr Williams’s family.
“We take the issues raised in the Coroner’s report extremely seriously and will be providing a formal response to the Coroner,” said a spokesperson for the Trust.
“Prior to this it would not be appropriate to comment.”
The Trust must now provide an explanation to the coroner of actions it has taken to prevent future deaths by Wednesday, November 13.