-Caveat Lector- Euphorian spotted this on the Guardian Unlimited site and thought you should see it.
------- Note from Euphorian: Cows, sheep, fish, juice, and NOW they're preying on their own! ------- To see this story with its related links on the Guardian Unlimited site, go to http://www.guardian.co.uk Hospital blunder leaves patients at risk of fatal brain disease James Meikle, health correspondent Tuesday October 29 2002 The Guardian Twenty-nine patients at a hospital in the north-east of England will be told within the next 24 hours that they have been exposed to possible infection from a deadly brain disease. They all underwent operations involving instruments that might previously have been used on a person being tested for CJD, a rare but incurable disease. The Department of Health last night confirmed "an appalling incident" had taken place at Middlesbrough general hospital in which the hospital had failed to prevent avoidable exposure to such diseases. Catastrophic errors in decontamination procedures and measures to ensure that equipment can be traced to their use in particular surgical procedures mean that health officials have little idea exactly which instruments might have been used in the operations that followed a brain operation on the CJD patient. The full extent of the calamity only dawned on hospital staff when the diagnosis of the patient was confirmed. The South Tees NHS trust said last night it was urgently bringing forward plans to inform patients who might have been exposed. The Department of Health said "crystal clear" guidance on decontamination procedures had been issued to the NHS in August 1999. "Instruments used on any suspected case of CJD must be quarantined immediately after use, pending the confirmation of diagnosis. "All NHS trusts must adhere to this guidance to prevent avoidable and unnecessary exposure to these diseases. In this case, it appears that the trust concerned has failed to do so. As a result some patients may have been put at risk. This is an appalling incident which reinforces the need to strictly adhere to our guidance." The original incident happened in July and Department of Health officials were given advice on how to handle the case at least a week ago, although the hospital said it only received this yesterday. The scale of the incident will alarm those who believe the government and medical establishment might have become complacent over the risk from CJD and its variant, the human form of BSE. The Guardian understands that the hospital did not follow advice that equipment used on confirmed or suspected cases of any type of CJD should not be used again. The instruments from the set used on the CJD case were apparently split between different sets of equipment after cleaning and decontamination. It is unclear exactly how traceable these were. In cases where operations are carried out on patients whose CJD symptoms were not apparent to medical teams at the time of surgery, guidance is in place to protect public health. The aim is to enable officials and doctors to trace patients whose operations followed closely after. In such cases the next six patients would normally be told of the potential risk. However, because the instruments in the Middlesbrough case appear to have been split between several sets of theatre equipment, nearly five times that number will be contacted. The lapse at Middlesbrough is likely to alarm even those health officials and medical personnel who are sceptical about the necessity of precautionary measures introduced over the use of blood, tissues and instruments in the wake of the BSE/vCJD fiasco. The South Tees trust last night said the CJD patient had a brain operation on July 19 and the diagnosis was confirmed on August 8. The equipment was then withdrawn. The trust had been working closely since then with the Department of Health's CJD surveillance unit "to look at any possible risk to these patients, though it must be stressed it is extremely low". The trust said it had been advised not to contact patients until further guidance was given. This was issued yesterday afternoon. The trust was "now meeting every individual to fully explain their unfortu nate circumstances ... We appreciate the distress and concern this news may cause to these patients, their families and the public at large". The incident calls into question government assurances that hospitals are responding effectively to the vCJD crisis. Individuals with human BSE have more potentially infective tissues than those with other forms of CJD. Ministers will now have to explain how procedures to protect the public seem to have gone wrong and reassure the public that this is an isolated incident. 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