Today's report, commissioned by Betsi Cadwaladr and delivered by Prof Brian Duerden, says "many inter-related issues came together to make a C.diff outbreak a significant risk", particularly at Ysbyty Glan Clwyd.
96 cases of the virus were recorded at the hospital between January and May 2013.
The report identifies these weaknesses in the system:
- There was a weak Infection Prevention & Control management structure, and a failure to recognise the risk indicated by the high background rate of C.diff infection
- There was a lack of Infection Prevention & Control leadership
- Infection Prevention & Control appears to have had a low priority
- There was a failure to respond in a timely manner to concerns about isolation capacity and infection risks
- There was a lack of single room isolation facilities and delays in isolating patients with diarrhoea that might be infectious, including potential C.diff cases
The number of specialist Infection Prevention & Control staff had been reduced, particularly at Ysbyty Glan Clwyd, resulting in:
- Inadequate training for ward staff
- Reduced support for ward Infection Prevention & Control activities
- Withdrawal of Infection Prevention & Control support for community hospitals and primary care
Wales' largest health board has admitted it needs to improve the way it deals with infection rates, as a highly critical report is published into an outbreak of Clostridium difficile (C.diff) earlier this year.
Betsi Cadwaladr University Health Board said "we must apologise to the people of North Wales that our infection control practices have not been as good as they should have been."
96 cases of the C.diff virus were recorded at Ysbyty Glan Clwyd, near Rhyl, between January and May 2013.
A report by Professor Brian Duerden from Cardiff University, commissioned by the health board and published today, said "significant" improvements need to be made in infection prevention and control.
We are fully aware of the strong feelings being expressed today regarding the relocation of the clinics from Flint Community Hospital to Borough Grove Clinic.
The Minister confirmed last month that the decisions made by the Health Board in January of this year were to be implemented and we are very keen to work closely with local people to take forward the plans to develop new services and facilities in Flint.
The health board is working hard to make sure there is a smooth transition of all clinics with minimum disruption for patients.
The spokesperson added: “We would like to reassure patients that the health clinic is a safe place to deliver our services. In the long term these services will be provided from a more modern Primary Healthcare Resource Centre.
"As of Monday, the phlebotomy, counselling and outpatient clinics previously provided from the hospital will be provided from the Borough Grove clinic building.
"On Monday 2nd September, GP Minor Surgery services will also transfer from the hospital to the clinic, following an upgrade of the current facilities.”
Campaigners who wanted to stage a sit-in at Flint Community Hospital over its imminent closure have instead protested peacefully outside after being turned away by police.
Betsi Cadwaladr University Health Board has said it is aware of the strong feeling about the decision, but their aim is modernisation.
Members of the Betsi Cadwaladr University Health Board have "fully and unequivocally" accepted the findings of a highly critical report on the Health Board’s management and governance arrangements.
At a public meeting today the board apologised for the failings that had been identified in an auditor's report and vowed to move ahead quickly to address the recommendations made.
We know the Report has left staff with many questions and has damaged public confidence in the way the Health Board has been operating. However I have been encouraged to see that the Betsi Cadwaladr Board are not shying away from these difficult issues, and I have found a real determination to make sure that this marks a turning point
We now have a clear plan and structure to drive forward the improvements that are needed, and I am pleased that these are in place. As we move forward we must make sure that we talk and listen to staff in the Health Board, as well as colleagues in partner organisations, to understand their concerns and reflect their views in our work
The Health Minister, Mark Drakeford, has welcomed the report into Betsi Cadwaladr Health Board. He says that the Chairman of the Health Board has confirmed his wish to resign, and that the Chief Executive of NHS Wales has been asked to appoint a successor.
I welcome this report from WAO and HIW. It is clear the board has been through a difficult period; however, many fundamental challenges still remain within the organisation.
The Chair has formally notified me of his wish to resign and I have accepted his resignation. The Chief Executive has also informed me of her intention to leave the organisation and the health board is currently working through the detail of her departure.
I wish to pay tribute to the efforts of the Chair and Chief Executive but I have asked David Sissling, Chief Executive of NHS Wales, to move forward swiftly to appoint their successors and enable the health board to begin a fresh chapter.
David has already taken robust steps to address the issues faced by the health board prior to today’s report being issued, and I will ask him to consider the report’s findings and inform me what further action is necessary.
The Chairman of Betsi Cadwaladr University Health Board is standing down after a report found failings which put patient's safety at risk.
Under the circumstances, I believe it is appropriate that I stand down as Chairman of Betsi Cadwaladr University Health Board, and I have informed the Minister of my intention to do so as soon as appropriate alternative arrangements are in place.
There are many fundamental challenges for the Board but I am confident that these will be responded to positively to deliver the necessary improvements and I shall continue to contribute fully during this transitional period.
Betsi Cadwaladr University Health Board will today formally receive a report by Healthcare Inspectorate Wales and the Wales Audit Office following their joint review of our governance arrangements. The report identified significant failings and major challenges for the Board which we recognise and accept.
Although steps have already been taken to tackle some of the issues, the Health Board is determined to respond to these matters in full and will ensure that the report’s recommendations are addressed as a priority.
Our progress will be subject to ongoing review and scrutiny by Healthcare Inspectorate Wales, the Wales Audit Office and Welsh Government.
"The Health Board's current governance arrangements and procedures do not adequately address the gap between the ward and the Board. We have concerns that the Board's governance arrangements and organisational structure are compromising its ability to properly identify issues concerning the quality and safety of patient care."
"The effectiveness of the Board has been significantly compromised by a breakdown in working relationships between some senior leaders in the organisation. There has been a lack of cohesion in the way executive directors work together and the report raises further concerns about the stability and capacity of the executive team as a result of staff turnover and sickness absence.
"Encouragingly, the Board recognises the scale of the challenges ahead and that strong leadership from the Chair and clinical leaders will be vital. The pace at which problems are tackled must accelerate."
Key points raised in the report include:
- Routine governance arrangements within the Health Board have not paid sufficient attention to infection control
- Effectiveness of the Board has been significantly compromised by a breakdown in working relationships between some senior leaders in the organisation
- There has been a lack of cohesion in the way executive directors work together
- The report raises further concerns about the stability and capacity of the executive team as a result of staff turnover and sickness absence.