Hawke's Bay Hospital used inadequately sterilised surgical equipment on patients

Mr Sud Rao (left), Dr Colin Hutchison, Dr Kevin Snee, CEO and Dr Nicholas Jones at a press conference at Hawke's Bay District Health Board about inadequate sterilisation of surgical equipment. Photo / Duncan Brown
Fifty-five patients from across Hawke's Bay now face HIV and hepatitis tests because inadequately sterilised surgical equipment may have been used on them.

Three children under the age of 16 and four people over the age of 70 are included in the group.

A batch of 91 pieces of equipment at Hawke's Bay Hospital were properly cleaned, heated to a high temperature and dried, but failed to go through the final sterilisation process overnight between February 1 and 2.

LIVE: Fifty-five patients from across Hawke's Bay now face HIV and hepatitis tests after a DHB sterilisation failure.

Posted by Hawke's Bay Today on Tuesday, 12 February 2019

Of those affected, 18 people were operated on in the main theatre block of Hawke's Bay Hospital.

The remaining packs were also sent to oral health and gynaecological clinics throughout Hawke's Bay, where they were then used by district nurses.

Hawke's Bay District Health Board executive director of Provider Services Colin Hutchison. Photo / Duncan Brown

At a press conference this morning, Hawke's Bay District Health Board executive director of Provider Services Colin Hutchison said they were made aware of the mistake on Monday, February 11, when a theatre nurse noticed the colour coding on a surgical tools packet was wrong, and notified a manager.

More than half the packs that were sent out were recalled before being used.

He said they have spoken to the majority of patients who have been identified at higher risk due to having invasive surgery. They will be invited to the hospital in the next few days to have care plans explained, Hutchison said.

"At this stage we've found that the community we've reached out to have been very understanding," he said.

Bacterial infections could be ruled out given the sterilisation process, and patients would only be tested for viral infections.

Those patients will now be tested for blood borne viruses – including HIV and Hepatitis B and C.

Hawke's Bay District Health Board clinical director of health improvement and equity Dr Nick Jones. Photo / Duncan Brown

The DHB's clinical director of health improvement and equity Dr Nick Jones said the tests would be made available to anyone exposed, but not to their families as "there is no risk to them".

Those interested would undergo a series of blood tests; this week, in six weeks and again in 24 weeks. But it will not be until the final test when patients could be given the all-clear.

Chief executive Kevin Snee apologised for any distress caused but stressed there was an "extremely remote chance" patients may have been at risk of infection.

Hawke's Bay District Health Board chief executive Dr Kevin Snee. Photo / Duncan Brown

"I take responsibility for this because I'm the head of the organisation," Snee said.

"Understandably the DHB is seeking answers as to how this failure occurred and we have launched an investigation to understand how this happened."

This investigation will be externally reviewed.

A review of processes to date had shown that this was the only occasion where the sterilisation process had not been completed, the DHB said.

"Our incident management team has consulted with local and national experts from the institute of Environmental Science and Research (ESR) as well as our own infectious disease specialist Dr Andrew Burns," Snee said.

"They have provided reassuring advice that the likelihood of patients becoming exposed to infection is extremely remote and highly unlikely."

Health Minister Dr David Clark said any incident such as this is of concern, and he felt for the patients involved.

"It is good to see the DHB taking a proactive approach. I'm advised the risk to patients is very low but the DHB is contacting patients directly and arranging follow-up tests. That seems appropriate in the circumstances."

Dr Clark said it is important that the DHB learns and shares any lessons identified as a result of this incident.

HBDHB chairman Kevin Atkinson said he is "very disappointed the issue has arisen" and has a great deal of sympathy for the patients affected.

"The Board will expect management to undergo a full and transparent investigation into the cause of the incident and report those findings as lessons learned so an incident like this can't happen again.

"However, I have been advised that management are confident that this has never happened before or since the incident, and relates to only one batch of equipment."

He said they had to wait until the investigation concluded to find out what the root cause was but would be surprised if the process was at fault.

Instead, he believed the "process wasn't followed".