A serious incident at the Bedford Renal Unit in February 2024 led to 69 dialysis patients developing anaemia, with 30 requiring blood transfusions – prompting the unit’s temporary closure.
Dr Justin Daniels, medical director at East and North Herts NHS Trust, told last night’s Health Overview and Scrutiny Committee (Monday 31 March) that the 97 patients who were treated there had to be given dialysis elsewhere.
“One patient had a high probability of being harmed as a result, and that patient suffered a stroke,” he said
“That patient has had significant problems as a result of that stroke.
The committee was told a patient safety incident investigation (PSII) found that a damaged water treatment system had compromised dialysis water quality.
“[This] meant that some of the chemicals which are normally in drinking water and need to be removed from dialysis were still in the water when it went to process the patients,” Dr Daniels said.
“We also realised that our risk management and some of our governance procedures were not as they should have been.”
Dr Daniels explained that the PSII went into more depth than a root cause analysis, which would have been carried out if this incident happened in the past.
“We identified 28 specific things that we were doing wrong, and 17 things that we needed to do very differently into the future,” he said.
“We have done the vast majority of those, we haven’t done all of them, but we will have done all of them fairly shortly,” he added.
The unit reopened in April 2024 after immediate safety actions and structural changes were implemented.
Councillor Graeme Coombes (Conservative, Wixams and Wilstead) asked: “Are you now satisfied that you can say to dialysis patients that if they come to your unit that they will be safe?
Dr Daniels said: “I don’t think in health care you can ever say that anything is 100 per cent safe, because I think I think that would be a lie.
“We will make them as safe as we possibly can make them.”
By John Guinn
Local Democracy Reporter
