An NHS Trust has admitted safety failings after employees were exposed to a potentially deadly strain of multi drug-resistant tuberculosis (TB) bacteria.
The incident took place in the microbiology laboratory at Royal Brompton Hospital in London on 17 January 2011. Staff were carrying out clinical diagnostics on samples of TB to assess if it was resistant to antibiotics. Several vials containing the bacteria were placed on a bench in the lab, when one rolled off and smashed on the floor.
Three employees were present in the lab, and one of them suffered a graze to her leg when the vial fell. They immediately evacuated the room and then removed their clothing in case they were transporting contaminants.
Although a specialist contractor was called the following day to fumigate the room, the spillage on the floor was cleared by a member of the hospital’s staff, who had not been provided with adequate RPE or PPE. Consequently, the worker was exposed to the bacteria. None of the exposed workers suffered any ill-health effects.
The HSE investigated the incident and identified numerous issues with the management and maintenance of the facility. These included:
The HSE issued a Prohibition Notice against Royal Brompton and Harefield NHS Foundation Trust, which ordered it to stop using the lab until adequate maintenance arrangements were put in place. It also served an Improvement Notice requiring the Trust to create suitable health and safety management procedures.
HSE inspector Mara Ajder said: “Multi drug-resistant TB is a potentially deadly bacterium. There are well-established practices for handling this agent safely, but in this case these practices simply weren’t met and several members of staff were exposed to a real risk of infection.
“The consequences of that one smashed vial could have been very serious, and the incident highlighted some serious flaws with controls and ways of working within the containment laboratory – a facility where the highest possible standards are necessary at all times.
Royal Brompton and Harefield NHS Foundation Trust appeared at Westminster Magistrates’ Court on 16 January and pleaded guilty to breaching s2(1) of the HSWA 1974. It was fined £12,500 and ordered to pay £25,000 in costs.
In mitigation, the Trust said it has now invested in the infrastructure of the lab and created a new management system, which monitors containment and control measures. The court also heard that the Trust had no previous safety convictions.
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