- Email: [email protected]
Crown Immunity and Food Poisoning in a Psychogeriatric Hospital
278
shame if Mr Ashley and his fellow dismiss the Stanley Royd report as campaigners for its task. For a start, there is quite a lot of inadequate evidence within it to sustain both of their contentions. As Mr Frank Dobson, the Labour front-bench spokesman on health, had succeeded in spotting by the time he made the final Opposition contribution to the debate, there is one section of the report which would appear to add new weight to Mr Ashley’s case. For the same environmental health officers whose testimony did so much to persuade Mr Hugill and his colleagues that the abolition of immunity could not have averted tragedy at Stanley Royd also provided the committee with some telling evidence that standards of inspection are unlikely to be as high as in the world outside so long as Crown Immunity lasts. "There was a difference between the approach of the [environmental health] officers to the inspections of hospital premises and the inspections of other premises" (para 219). The officers saw themselves primarily as law enforcement officers; but in NHS hospital kitchens, having no law to enforce, they regarded themselves merely as visitors and advisers. Moreover, their judgment on standards in these kitchens could be softened by their awareness that resources to remedy such conditions could probably not be found: "in the case of Stanley Royd, they were persuaded that lack of money meant that nothing much could be done". And though the report shows that in some cases the authorities responsible for Stanley Royd were not even spending the money they had got-the district nursing budget, as Mr Fowler pointed out in the House, was actually underspentthe whole portrait of Stanley Royd, its vulnerable inhabitants and its heroic and overstretched staff, powerfully proclaims a service crying out for money. A building put up in Bonaparte’s day, to serve as the West Riding Paupers’ Asylum. Kitchens variously described as "Dickensian" and "a culinary disaster", archaically equipped, and in the high summer (which it was at the time of this outbreak) often intolerably hot. Many patients (830 at this time), a third more than 75 years old, a quarter resident there for 29 years or more. Shortages of consultants, of nurses, and of kitchen staff But it would be
Commentary from Westminster Crown
Immunity and Food Poisoning in a Psychogeriatric Hospital THE House of Commons spent nearly an hour on the day of publication discussing the report of the Hugill inquiry into the outbreak of food poisoning in August 1984, at Stanley Royd Hospital, Wakefield (see p 279). Much of this time was wasted. Most MPs had not had anything like adequate time to look at the report before the Social Services Secretary, Mr Norman Fowler, made his statement on it. Some prefaced their comments with frank admissions that they had yet to read the document. Others appeared to have whipped through it picking out points that attracted them, but without being able to relate these points to the argument as a whole. Several took their chance to repeat public criticisms made at the time of the outbreak, without bothering to note-and probably without even realising-that these contentions had been authoritatively rejected by the Hugill inquiry. Several of those who intervened were obviously hoping to the Stanley Royd report to,reinforce previous campaigns for greater public spending on the hospital service, and for the lifting of the provision which makes bad practices, open to swingeing penalties when they occur almost anywhere else, immune from prosecution if they happen in NHS hospitals. But here they were in a difficulty, since the Hugill report had failed to arrive at the conclusions they had expected-a fact of which Mr Fowler took full advantage.
use
The heart of the trouble, he argued, was clearly human error, compounded by the failure of supervisors to supervise and of management to manage. The system of Crown Immunity had not, in the view of Mr Hugill and his colleagues, been to blame. The evidence submitted to them, they had reported, did not support abolition: "We find it quite impossible to recommend any change in the law on the vexed question of Crown Immunity, where the entirety of the evidence given to us by the professional environmental health officers was to the effect that the sanctions of the criminal law would not have been employed in respect of the kitchen at Stanley Royd, even if they had been available". And on resources, the Government at least-on Mr Fowler’s reading of the report-was safe from blame. In the view of the Hugill report, the question of financial restraints or constraints above the level of the region was not relevant to any of the issues before it-a conclusion supported, the report added, by evidence from witnesses from the Yorkshire Health
Authority. This brisk dismissal of Opposition preconceptions made for some tetchy and uncharitable exchanges, especially with the House’s most ferocious scourge of the Crown Immunity system, Mr Jack Ashley (Lab, Stoke South). He seemed to have concluded that if the report was saying things like this it could hardly be worth serious attention. "One of the most disgracefully complacent Ministerial statements ever to be made in the chamber" he called Mr Fowler’s announcement-which is a very big claim indeed, as any regular Westminster attender would tell you. "Regardless of what the report says," he told the Minister, "the only way to solve the problem is to abolish Crown Immunity, prosecute negligent authorities, and provide the funds needed to end the scandal once and for all".
a
were to
(with problems made worse by high rates of staff sickness, so that those who should have been superintending had.to carry out the work). A spending rate of f25 per patient per day, when the average in such places was nearerC40. And if nurses not be found, then some of the reasons seem obvious enough: the ancient, impractical fabric; and work to be performed within it which might sometimes, as Hugill compassionately notes, "defy description". A Government which believes in market forces should surely conclude that present incentives must be inadequate.
could
There is, too, a powerfully troubled passage (para 275-281) warning of what might happen if the switch from institutional to community care, and the maintenance of services for those who must stay as the institution runs down, are allowed to proceed at Stanley Royd without adequate funding. There are no doubt many other places up and down the land about which these words could equally well be written.
Some of these issues will be raised next Friday, during the second reading debate on a private member’s Bill to get rid of Crown Immunity. (Last week’s proceedings, incidentally, should have disabused Mr Fowler of any notion that he can satisfy the clamour simply by using a system of "Crown Notices", ordering enforcement in areas covered by
279
Hugill suggests: Mr Ashley and company do Hugill’s confidence that this system has been working well.) But the wider implications of the report await considered examination. Some MPs who spoke last week, all too aware of the thinness and frailty of their first impressions, immunity,
not
as
share
intend
to
press for
a
full debate. DAVID MCKIE
Public Health Poisoning in a Psychogeriatric Hospital
The 1984 Outbreak of Food
Sunday, Aug 26, 1984, the junior medical officer on duty at Stanley Royd Hospital, Wakefield, a psychogeriatric hospital with some 950 beds, was called to see a patient with diarrhoea. By 9.15 PM 94 patients were similarly afflicted and 1 of At 7 AM
on
them died at 11.35PM. Of 788 patients resident in the hospital on Aug 26, 355 became ill in this outbreak with suspected salmonellosis, from 218 of whom positive specimens were obtained. Specimens were positive in another 81 symptom-free patients. Among the patients, there were 19 deaths due to, or contributed to by, salmonella food poisoning. Of a total staff of 980, 106 had suspected salmonellosis, of whom 51 gave positive specimens; and 29 symptom-free members of the staff were also positive. The cause was identified as Salmonella typhimurium phage type 49, the commonest form of salmonella, which accounted in 1983 for 12% of reported outbreaks of food poisoning in England where the source was discovered. On Nov 2, 1984, the Secretary of State for Social Services, Mr Norman Fowler, appointed a committee of inquiry* under the NHS and the Public Health (Control of Disease) Acts. The committee, whose report was published last week, was asked to investigate the source of the outbreak, any factors contributing to its spread, and the adequacy of measures taken to investigate, deal with, and contain the outbreak.
Since the outbreak Wakefield Health Authority had made a number of improvements in the kitchen and its management. The Secretary of State was instructing them and the Yorkshire Regional Health Authority to consider all the points raised by the report and to tell him urgently of the action they had taken and proposed to take. The report identified serious failures of supervision and management. General managers had now been appointed by the Yorkshire Regional Health Authority and Wakefield Health Authority. As in all authorities, Mr Fowler pointed out, these managers carried clear and personal responsibility for securing effective action. The Government, he added, would continue the urgent review of Crown Immunity for hospital kitchens, including the suggestion in the report that a "Crown Notice" form of procedure should be initiated (see our Parliamentary comment on p
278).
Fowler announced that he was urgently reviewing Departmental guidance to health authorities on the steps they must take to ensure proper food hygiene in hospitals and to ensure that environmental health officers were encouraged to visit and that proper regard was paid to their recommendations. He was referring Mr
committee’s recommendations about the arrangements for the control of infection and the handling of outbreaks to the Hospital Infection Working Group, which was set up last summer to advise on the revision of Departmental guidance on control of infection. Mr Fowler was asking the group to give the highest priority to contingency plans for dealing with outbreaks of infection-plans that would ensure that specialist help was brought in as soon as it was needed. He had decided that it would be right to establish an inquiry into the future development of the public health function, including the control of communicable diseases, and the specialty of community medicine in England. The inquiry would be a broad and fundamental examination of the role of public health doctors, including how such a role could best be fulfilled. The inquiry would be chaired by the Government’s chief medical officer, Dr Donald Acheson, and Mr Fowler expected to receive its report before the end of the year. to the
The Part Played
Mr Fowler’s
the Report
Response Presenting the report in the House of Commons on Jan 21, the Secretary of State said that the conclusion was that the Salmonella was probably brought into the kitchen in contaminated chickens, and that cold roast beef was the most likely vehicle of infection. This infection was able to multiply because the beef was not properly refrigerated. The committee found that a number of unhygienic and unsatisfactory practices had grown up in the hospital kitchen. The report paid tribute to the work of the junior doctors on duty during the early days of the outbreak and the care given by nursing staff on the wards. These staff were working under very difficult conditions and their efforts were in the highest traditions of their professions. The committee criticised a number of matters. In particular, they commented on the failure to ensure satisfactory management of the kitchen at the hospital. They criticised medical and nursing management and in particular the failure to seek, or accept offers of, help from outside specialists, both in the investigation of the outbreak and in the treatment of the patients affected by it. The regional health authority and some officers at regional and district level were criticised for failing fully to inform themselves first hand of the situation
to
once
the outbreak had begun.
*The members of the committee were: Mr John Hugill, QC, Recorder of the Crown Court; Prof Rosalmde Hurley, professor of microbiology, Institute of Obstetrics and Gynaecology, University of London, and chairman, Medicines Commission; Mr P. A. J. Salmon, chairman, South West Surrey Health
Authority. 1 Department of Health and Social Security. Report of the committee of inquiry into a outbreak of food poisoning at Stanley Royd Hospital. London: HM Stationery Office Cmnd 9716. £8.80.
by the Press and Media One section of the report, commenting on this aspect of the outbreak, concludes: "Some newspaper reporters approached patients and staff within and without the hospital in order to make their reports more personal and, no-one would deny, more sensational as well as informed. We do not think it right that the patients at a hospital such
Stanley Royd should be asked to make informal comments or that their comments should receive widespread publicity. Nor do we think it fair that the staff, working under the pressure that existed at the hospital, should be pressed to make statements unless they wished to do so, as some did. It was suggested to us that the press briefings by management were inadequate, though we were only given one example of this in that it was said that reporters were not allowed to visit the kitchen premises for "no clear reason". It might be said that it is obviously undesirable, and unhygienic, for strangers to visit the premises of a kitchen in the middle of a widespread epidemic of food poisoning for which it is at least possible the kitchen is responsible. One reporter, having decided that overriding consideration of public interest justified his using other than straightforward means of obtaining information, entered the kitchen premises with a photographer, the one wearing and the other carrying a white coat, one labelled ’Enteric Pathogens’. They succeeded in entering the kitchen and taking photographs which appeared in the national press. We doubt whether the interests of the public were much satisfied by these photographs and if they or the information obtained by this ruse justified the risks involved, though the reporter’s opinion, that the kitchen premises appeared to be being given a thorough clean but were taking a long time to reach the required standard, was confirmation of the other evidence we obtained." as
shame if Mr Ashley and his fellow dismiss the Stanley Royd report as campaigners for its task. For a start, there is quite a lot of inadequate evidence within it to sustain both of their contentions. As Mr Frank Dobson, the Labour front-bench spokesman on health, had succeeded in spotting by the time he made the final Opposition contribution to the debate, there is one section of the report which would appear to add new weight to Mr Ashley’s case. For the same environmental health officers whose testimony did so much to persuade Mr Hugill and his colleagues that the abolition of immunity could not have averted tragedy at Stanley Royd also provided the committee with some telling evidence that standards of inspection are unlikely to be as high as in the world outside so long as Crown Immunity lasts. "There was a difference between the approach of the [environmental health] officers to the inspections of hospital premises and the inspections of other premises" (para 219). The officers saw themselves primarily as law enforcement officers; but in NHS hospital kitchens, having no law to enforce, they regarded themselves merely as visitors and advisers. Moreover, their judgment on standards in these kitchens could be softened by their awareness that resources to remedy such conditions could probably not be found: "in the case of Stanley Royd, they were persuaded that lack of money meant that nothing much could be done". And though the report shows that in some cases the authorities responsible for Stanley Royd were not even spending the money they had got-the district nursing budget, as Mr Fowler pointed out in the House, was actually underspentthe whole portrait of Stanley Royd, its vulnerable inhabitants and its heroic and overstretched staff, powerfully proclaims a service crying out for money. A building put up in Bonaparte’s day, to serve as the West Riding Paupers’ Asylum. Kitchens variously described as "Dickensian" and "a culinary disaster", archaically equipped, and in the high summer (which it was at the time of this outbreak) often intolerably hot. Many patients (830 at this time), a third more than 75 years old, a quarter resident there for 29 years or more. Shortages of consultants, of nurses, and of kitchen staff But it would be
Commentary from Westminster Crown
Immunity and Food Poisoning in a Psychogeriatric Hospital THE House of Commons spent nearly an hour on the day of publication discussing the report of the Hugill inquiry into the outbreak of food poisoning in August 1984, at Stanley Royd Hospital, Wakefield (see p 279). Much of this time was wasted. Most MPs had not had anything like adequate time to look at the report before the Social Services Secretary, Mr Norman Fowler, made his statement on it. Some prefaced their comments with frank admissions that they had yet to read the document. Others appeared to have whipped through it picking out points that attracted them, but without being able to relate these points to the argument as a whole. Several took their chance to repeat public criticisms made at the time of the outbreak, without bothering to note-and probably without even realising-that these contentions had been authoritatively rejected by the Hugill inquiry. Several of those who intervened were obviously hoping to the Stanley Royd report to,reinforce previous campaigns for greater public spending on the hospital service, and for the lifting of the provision which makes bad practices, open to swingeing penalties when they occur almost anywhere else, immune from prosecution if they happen in NHS hospitals. But here they were in a difficulty, since the Hugill report had failed to arrive at the conclusions they had expected-a fact of which Mr Fowler took full advantage.
use
The heart of the trouble, he argued, was clearly human error, compounded by the failure of supervisors to supervise and of management to manage. The system of Crown Immunity had not, in the view of Mr Hugill and his colleagues, been to blame. The evidence submitted to them, they had reported, did not support abolition: "We find it quite impossible to recommend any change in the law on the vexed question of Crown Immunity, where the entirety of the evidence given to us by the professional environmental health officers was to the effect that the sanctions of the criminal law would not have been employed in respect of the kitchen at Stanley Royd, even if they had been available". And on resources, the Government at least-on Mr Fowler’s reading of the report-was safe from blame. In the view of the Hugill report, the question of financial restraints or constraints above the level of the region was not relevant to any of the issues before it-a conclusion supported, the report added, by evidence from witnesses from the Yorkshire Health
Authority. This brisk dismissal of Opposition preconceptions made for some tetchy and uncharitable exchanges, especially with the House’s most ferocious scourge of the Crown Immunity system, Mr Jack Ashley (Lab, Stoke South). He seemed to have concluded that if the report was saying things like this it could hardly be worth serious attention. "One of the most disgracefully complacent Ministerial statements ever to be made in the chamber" he called Mr Fowler’s announcement-which is a very big claim indeed, as any regular Westminster attender would tell you. "Regardless of what the report says," he told the Minister, "the only way to solve the problem is to abolish Crown Immunity, prosecute negligent authorities, and provide the funds needed to end the scandal once and for all".
a
were to
(with problems made worse by high rates of staff sickness, so that those who should have been superintending had.to carry out the work). A spending rate of f25 per patient per day, when the average in such places was nearerC40. And if nurses not be found, then some of the reasons seem obvious enough: the ancient, impractical fabric; and work to be performed within it which might sometimes, as Hugill compassionately notes, "defy description". A Government which believes in market forces should surely conclude that present incentives must be inadequate.
could
There is, too, a powerfully troubled passage (para 275-281) warning of what might happen if the switch from institutional to community care, and the maintenance of services for those who must stay as the institution runs down, are allowed to proceed at Stanley Royd without adequate funding. There are no doubt many other places up and down the land about which these words could equally well be written.
Some of these issues will be raised next Friday, during the second reading debate on a private member’s Bill to get rid of Crown Immunity. (Last week’s proceedings, incidentally, should have disabused Mr Fowler of any notion that he can satisfy the clamour simply by using a system of "Crown Notices", ordering enforcement in areas covered by
279
Hugill suggests: Mr Ashley and company do Hugill’s confidence that this system has been working well.) But the wider implications of the report await considered examination. Some MPs who spoke last week, all too aware of the thinness and frailty of their first impressions, immunity,
not
as
share
intend
to
press for
a
full debate. DAVID MCKIE
Public Health Poisoning in a Psychogeriatric Hospital
The 1984 Outbreak of Food
Sunday, Aug 26, 1984, the junior medical officer on duty at Stanley Royd Hospital, Wakefield, a psychogeriatric hospital with some 950 beds, was called to see a patient with diarrhoea. By 9.15 PM 94 patients were similarly afflicted and 1 of At 7 AM
on
them died at 11.35PM. Of 788 patients resident in the hospital on Aug 26, 355 became ill in this outbreak with suspected salmonellosis, from 218 of whom positive specimens were obtained. Specimens were positive in another 81 symptom-free patients. Among the patients, there were 19 deaths due to, or contributed to by, salmonella food poisoning. Of a total staff of 980, 106 had suspected salmonellosis, of whom 51 gave positive specimens; and 29 symptom-free members of the staff were also positive. The cause was identified as Salmonella typhimurium phage type 49, the commonest form of salmonella, which accounted in 1983 for 12% of reported outbreaks of food poisoning in England where the source was discovered. On Nov 2, 1984, the Secretary of State for Social Services, Mr Norman Fowler, appointed a committee of inquiry* under the NHS and the Public Health (Control of Disease) Acts. The committee, whose report was published last week, was asked to investigate the source of the outbreak, any factors contributing to its spread, and the adequacy of measures taken to investigate, deal with, and contain the outbreak.
Since the outbreak Wakefield Health Authority had made a number of improvements in the kitchen and its management. The Secretary of State was instructing them and the Yorkshire Regional Health Authority to consider all the points raised by the report and to tell him urgently of the action they had taken and proposed to take. The report identified serious failures of supervision and management. General managers had now been appointed by the Yorkshire Regional Health Authority and Wakefield Health Authority. As in all authorities, Mr Fowler pointed out, these managers carried clear and personal responsibility for securing effective action. The Government, he added, would continue the urgent review of Crown Immunity for hospital kitchens, including the suggestion in the report that a "Crown Notice" form of procedure should be initiated (see our Parliamentary comment on p
278).
Fowler announced that he was urgently reviewing Departmental guidance to health authorities on the steps they must take to ensure proper food hygiene in hospitals and to ensure that environmental health officers were encouraged to visit and that proper regard was paid to their recommendations. He was referring Mr
committee’s recommendations about the arrangements for the control of infection and the handling of outbreaks to the Hospital Infection Working Group, which was set up last summer to advise on the revision of Departmental guidance on control of infection. Mr Fowler was asking the group to give the highest priority to contingency plans for dealing with outbreaks of infection-plans that would ensure that specialist help was brought in as soon as it was needed. He had decided that it would be right to establish an inquiry into the future development of the public health function, including the control of communicable diseases, and the specialty of community medicine in England. The inquiry would be a broad and fundamental examination of the role of public health doctors, including how such a role could best be fulfilled. The inquiry would be chaired by the Government’s chief medical officer, Dr Donald Acheson, and Mr Fowler expected to receive its report before the end of the year. to the
The Part Played
Mr Fowler’s
the Report
Response Presenting the report in the House of Commons on Jan 21, the Secretary of State said that the conclusion was that the Salmonella was probably brought into the kitchen in contaminated chickens, and that cold roast beef was the most likely vehicle of infection. This infection was able to multiply because the beef was not properly refrigerated. The committee found that a number of unhygienic and unsatisfactory practices had grown up in the hospital kitchen. The report paid tribute to the work of the junior doctors on duty during the early days of the outbreak and the care given by nursing staff on the wards. These staff were working under very difficult conditions and their efforts were in the highest traditions of their professions. The committee criticised a number of matters. In particular, they commented on the failure to ensure satisfactory management of the kitchen at the hospital. They criticised medical and nursing management and in particular the failure to seek, or accept offers of, help from outside specialists, both in the investigation of the outbreak and in the treatment of the patients affected by it. The regional health authority and some officers at regional and district level were criticised for failing fully to inform themselves first hand of the situation
to
once
the outbreak had begun.
*The members of the committee were: Mr John Hugill, QC, Recorder of the Crown Court; Prof Rosalmde Hurley, professor of microbiology, Institute of Obstetrics and Gynaecology, University of London, and chairman, Medicines Commission; Mr P. A. J. Salmon, chairman, South West Surrey Health
Authority. 1 Department of Health and Social Security. Report of the committee of inquiry into a outbreak of food poisoning at Stanley Royd Hospital. London: HM Stationery Office Cmnd 9716. £8.80.
by the Press and Media One section of the report, commenting on this aspect of the outbreak, concludes: "Some newspaper reporters approached patients and staff within and without the hospital in order to make their reports more personal and, no-one would deny, more sensational as well as informed. We do not think it right that the patients at a hospital such
Stanley Royd should be asked to make informal comments or that their comments should receive widespread publicity. Nor do we think it fair that the staff, working under the pressure that existed at the hospital, should be pressed to make statements unless they wished to do so, as some did. It was suggested to us that the press briefings by management were inadequate, though we were only given one example of this in that it was said that reporters were not allowed to visit the kitchen premises for "no clear reason". It might be said that it is obviously undesirable, and unhygienic, for strangers to visit the premises of a kitchen in the middle of a widespread epidemic of food poisoning for which it is at least possible the kitchen is responsible. One reporter, having decided that overriding consideration of public interest justified his using other than straightforward means of obtaining information, entered the kitchen premises with a photographer, the one wearing and the other carrying a white coat, one labelled ’Enteric Pathogens’. They succeeded in entering the kitchen and taking photographs which appeared in the national press. We doubt whether the interests of the public were much satisfied by these photographs and if they or the information obtained by this ruse justified the risks involved, though the reporter’s opinion, that the kitchen premises appeared to be being given a thorough clean but were taking a long time to reach the required standard, was confirmation of the other evidence we obtained." as