Delayed action on Legionella outbreak in Mayo hospital
NO action was taken in respect of an outbreak of Legionella in a Mayo hospital unit for four months despite it being highlighted, it has been learned, writes CLAIRE MCNAMARA
A major investigation was launched by the HSE in the county in February 2019 over the failure to notify the Mayo Mental Health Services and infection control regarding the positive detection of Legionella in St. Anne's Unit at the Sacred Heart Hospital in Castlebar.
Documents released to The Connaught Telegraph under the Freedom of Information Act highlight that Legionella was present in St. Anne's Unit for four months before the positive result was relayed to the area management team meeting and infection control.
Legionellosis is the collective name given to the pneumonia like illness caused by legionella bacteria, including the most serious Legionnaires’ disease.
Infection is caused by breathing in small droplets of water contaminated by the bacteria.
Common symptoms include coughing, breathlessness, high fever, muscle aches and headaches, which usually disappear five to six days after infection but may take longer.
An email sent by Dr. Elaine Walsh on March 14, 2019, to the Mayo Mental Health Management Team highlighted her concerns regarding the detection of Legionella in St. Anne's Unit.
However, at the time she was unsure if a review of this was proposed and how it was currently being monitored.
In her email she stated she had concerns regarding the delay from November 2018 until February 2019 in relaying the positive result, particularly in view of the fact that she had highlighted concerns prior to Christmas with what appeared to be an increase in respiratory infections in their patient cohort in St. Anne's.
“Allegedly, three areas in St. Anne's have tested positive for Legionella.” A clinical nurse manager “has only been able to find out information on one area, which I believe is the sink in the staff room. The other two areas have not been identified to her.”
Dr. Walsh referenced ‘a reluctance’ to inform the Public Health Unit in Galway regarding the positive findings, which she discussed with the infection control nurse.
However, the nurse stated that because they had no positive results for any of the patients, this is one of the reasons that Public Health was not informed.
Meanwhile, Dr. Walsh further stated to the nurse that they had no positive results in patients because it has to be specifically requested by a doctor at the time and will not show up on ordinary testing of a patient.
Dr. Walsh also stated that she was aware of Public Health being involved in other CHO areas where Legionella has been identified in HSE units, but no patients proved positive.
“Also, a clinical nurse manager has asked for testing of the water system in the kitchen in the headquarters, as ‘we apparently are on the same water supply’ and this has been refused to date.”
Dr. Walsh concluded by saying she was 'only interested in ensuring that we are doing everything we should be doing and that patients and staff are fully protected'.
Further correspondence shows that Dr. Ursala Skerritt, executive clinical director of Mayo Mental Health Services, wrote to Mr. Steve Jackson, general manager, CHO 2 – Mental Health Services, on February 19, 2019, regarding the delay in relaying the positive Legionella result.
Her email to Mr. Jackson stated that they had just finished the area management team (AMT) meeting, which began with an extraordinary meeting of the AMT and senior nursing staff called by her with the infection control nurse to discuss this issue.
“Of concern is the fact that the sample referred to was taken on October 25th, 2018, and the result provided on the 6th of November, 2018, and yet today (February 19, 2019) was the first time the result was notified to the AMT and infection control.
“This warrants an urgent investigation as to whether all protocols and policies were adhered to in the management of this issue.
“While not being in full possession of all the facts just yet, the lack of notification to any clinician would pose a serious risk to patients and staff in the units affected and further to all areas of Mayo Mental Health Services and will require further clarity.”
At the time she stated the matter required urgent attention and they were awaiting a result from the two patients currently in-patients of Mayo University Hospital and who were admitted from two approved centres.
In a response to a request for comment the HSE said: “The management of Legionella in the Mayo Mental Health Services is the responsibility of our maintenance department and this includes the cleaning of tanks by a contracted specialist company, sample testing and weekly flushing.
“In November 2018, following sample testing by a specialist company, traces of Legionella were found in some areas and results were given to the maintenance department.
“The maintenance staff took the necessary steps to manage the situation appropriately. The prevention and infection control nurse was made aware of this in February 2019 and the AMT was informed.
“Following this, additional sampling took place and the results showed that a reduced level on the second sample, while no service-user or staff member tested positive for Legionella.
“Separately, a specialist company was subsequently engaged to carry out risk assessments and following receipt of their recommendation, the following was agreed:
“A log book to be maintained for all areas recording water temperature, tank cleaning and decontamination, all water tanks will continue to be cleaned by an out-sourced company, the cleaning and descaling of TMVs in the approved centres will be carried out by our maintenance staff, and weekly flushing system, already in place, to continue.
“Meanwhile, it has been agreed that the AMT will be briefed, as necessary, on these matters.”