Medical chief sorry for shirking blame over CJD scare

Health Editor,Jeremy Laurance
Friday 28 February 2003 20:00 EST
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The government's chief medical officer has apologised to patients and families caught up in a CJD scare after an independent inquiry criticised the Department of Health for trying to shift the blame for the incident on to the hospital where it happened.

Professor Sir Liam Donaldson ordered the inquiry because 24 people were left at theoretical risk of contracting Creutzfeldt-Jakob's disease when they had surgery at Middlesbrough General Hospital with instruments used on a woman later diagnosed with the disease.

Yesterday the inquiry, headed by Bill Kirkup, regional director of public health in the North-east, exonerated the hospital and praised its staff.

But it criticised the media team at the Department of Health for accusing the hospital of blundering, which added to the "needless significant public distress". The finding is particularly embarrassing for Sir Liam, who has campaigned for a "no-blame" culture in the health service to encourage greater openness on medical errors.

The scare began after surgeons who had performed an exploratory brain operation on a woman with signs of dementia sent a sample of tissue to be tested at the CJD surveillance Unit in Edinburgh.

The woman showed no clinical signs of the disease but the surgeons who sent the tissue sample said it was a "belt and braces" move to check. When the diagnosis came back positive for sporadic CJD, it was too late to protect other patients – the instruments used in the operation on the woman had been subsequently used in surgery on 24 other patients.

When the story broke on 30 October, the Department of Health issued a highly critical statement, based on a briefing from the CJD Incidents Panel, referring to the "appalling" incident and claiming that the hospital had failed to follow "crystal clear" guidance on decontaminating instruments.

The inquiry report found no grounds for the CJD Incidents Panel's conclusion that the hospital's standard of decontamination was "inadequate".

It recommended that all instruments used in brain biopsy operations be quarantined until the diagnosis was clear. The Department of Health said it would implement the recommendation.

* The worst of the variant CJD epidemic in Britain might be over, a new analysis suggests. Studies of the annual number of deaths from vCJD published in The Lancet found that they have fallen from a peak of 28 in 2000 to 17 in 2002.

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