We are sorry for any ongoing distress to the family of Mrs Kaur and our deepest sympathies remain with them at this difficult time.
We understand the anxiety of families where they have to wait for information on the cause of death, however in this case the information was awaited from the Procurator Fiscal. The Procurator Fiscal determined that the cause of death was Influenza A&B and therefore mould did not contribute to the death.
At all times the safety of patients is at the centre of our decision making and that is why Incident Management Teams review infections and advise on action that should be taken.
We have been fully transparent in our reporting of two cases of mucor through our governance committees and the minutes from these meetings are on our public website https://www.nhsggc.org.uk/media/255421/item-13b-ccg-m-19_02-tbr.pdf
Further to that, we today publish the seven findings from the Incident Management Team (IMT) into these cases, to demonstrate what action was taken. These findings, prepared by the IMT who were responsible for the investigation into the two cases, set out clearly that mucoraceous mould was not found in the environment.
Whilst there was other fungi and mould found – that associated with the infection suffered by Mrs Kaur was not. The IMT directed a number of actions to be taken and the details of the findings are as follows:
- Air sampling of the ICUs was negative for mucoraceous moulds
- Linen has been reported in previous outbreaks and therefore the linen process was reviewed. Staff were asked about a history of damp linen and linen was swabbed. Swabs were negative and there were no concerns noted regarding the laundering or linen transfer/storage processes
- Review of tracheostomy sets, no issues found and it was noted that equipment is disposable
- Other common equipment was explored and swabs of ultrasound equipment taken – these were negative
- Equipment storage area checked for water ingress , no evidence of such
- The dialysis point was explored. There was a history of a water leak on 4/1/19 and a repair on 6/1/19, 3 days before patient 1 was admitted to the room. The panel of the dialysis point was removed and inspected. Pulp type material was found, removed and sent to the lab for culture. The plumbing connection to a dirty utility space was raised as a concern and remedied. Results of swabs and culture of pulp revealed yeasts/mould but not mucoraceous moulds. Further exploration of the room was undertaken to look for mould which included checking flooring and sink panels. No evidence of water ingress or mould was found in these areas
- Validation was undertaken of the room before putting it back into clinical use and the results were satisfactory.