§ LORD DENHAMMy Lords, my right honourable friend the Secretary of State for Social Services is making a Statement in another place on contaminated infusion fluids. It has been agreed through the usual channels that this Statement need not be repeated in your Lordships' House, but I will arrange for it to be inserted in the OFFICIAL REPORT.
233 Following is the Statement:
"With permission, Mr. Speaker, I should like to make a statement on the Report of the Committee which, the House will recall, I appointed, under the chairmanship of Mr. C. M. Clothier, Q.C., to inquire into the circumstances which led to the use of contaminated dextrose infusion fluids at Devonport Hospital and which involved the death of five patients. The Report has been published to-day and copies are available in the Vote Office.
"The Committee conclude—in their own words (paragraph 79):
'that the fundamental cause of this disaster is to be found in human failings at Evans Medical, ranging from simple carelessness to poor management of men and plant. The Committee heard of no imminent technological advance in the field of production of intravenous fluids which will eliminate need for skilful men devoted to their work. The Committee consider that too many people believe that sterilisation of fluids is easily achieved with simple plant operated by men of little skill under a minimum of supervision, a view of the task which is wrong in every respect.'"The Government accept the Report, and I have referred to the Medicines Commission a number of technical recommendations. These include consideration of the use of plastic containers, methods of identifying individual batches of dextrose, sterility testing methods, the possibility of incorporating bacterial filters and technical advice on the maintenance of autoclaves. There are also recommendations on prevention of contamination during cooling and after distribution." Steps have been taken in my Department to improve its methods for dealing with reports of defective supplies. I have had extracts from the Report which illustrate good practice in the production of infusion fluids circulated to manufacturers of sterile products. A meeting with nurses, doctors and pharmacists to discuss a number of points on hospital procedure has taken place and recommendations will be circulated as soon as they are finally agreed.
"Officers of my Department have visited a sample of hospitals and identified in some of them necessary improvements in the organisation of 234 sterilising facilities. Some can be made at once, and others only after suspension of operations for a period. These hospitals have been advised accordingly. All hospitals within the National Health Service which produce their own sterile infusion fluids have been asked to examine their production methods in the light of the Guide to Good Pharmaceutical Manufacturing Practice. Where the organisation requires improvements which cannot quickly be secured, hospitals have been asked to seek other sources of supply until the necessary improvements have been made.
"I should like to thank Mr. Clothier and his colleagues for their urgent and penetrating review of the causes of this tragedy, and for their technical and other recommendations. Some have already been acted upon: all will have urgent attention."