Investigation launched after 'lapses in care' identified at Peterborough City Hospital following patient's death from MRSA

An investigation has been launched at Peterborough City Hospital after lapses in care were identified following the death of a patient who had contracted MRSA.

The patient died after contracting the virus at the hospital in June this year it has been revealed.

An issue relating to cancer patients receiving an underdose of radiation was also reported.

Now the Chief Nurse has said the hospital will learn from the incidents.

Lapses relate to wound management

In papers from the latest North West Anglia NHS Foundation Trust board meeting, it was revealed that ‘lapses in care’ had been identified in the care of the patient who died from MRSA.

The report said: “One case of hospital acquired MRSA bacteraemia, on the PCH site, was reported in June 2022. The patient has since died and due to lapses in care identified during the post

infection review this will now be investigated as a serious incident.”

The trust said the investigation was still ongoing, and the ‘lapses in care around wound care’ related to the wound not being appropriately managed.

Cancer patients given ‘underdose of radiation’

Other issues revealed in the papers included a ‘serious incident’ in relation to radiotherapy treatment between June 2021 and May 2022.

An error on a machine led to 21 cancer patients at the hospital getting an underdose of radiation by approximately 27%.

The report said: “All patients were contacted by the radiotherapy clinical team, and full Duty of Candour conversations took place. Patients were brought back into clinic and assessed for treatment response.”

The trust said that to date there has been no harm to patients.

Patient fell from window

Another serious incident occurred at Hinchingbrooke Hospital, where ‘a patient was perceived to have fallen from a 1st floor window to the ground below’ in September last year.

The trust said that A CQC investigation into the incident had been launched..

The trust said the patient sustained injuries that were treated appropriately at the time. The CQC are currently undertaking their own investigation following a Health and Safety Executive investigation, for which the trust are awaiting the outcome.

The patient has recovered well and at is home with family.

Incidents ‘represent extremely small number of patients’

Jo Bennis, Chief Nurse, stated: “It is really important that the Trust has a culture of being open and honest when it makes mistakes so that we can learn from them.

"Whilst we would not want any patient to come to harm there are incidents that occur where we have not as an organisation delivered the best care possible. We see a large number of patients in the organisation each day through a variety of pathways, the serious incidents mentioned in the Board papers from our last public meeting thankfully represent an extremely small number of patients, but we believe that it is very important to be completely transparent.”

The full board papers are available at https://www.nwangliaft.nhs.uk/about-us/trust-board/board-papers-meetings/