A healthcare worker at a Worcestershire hospital contracted the Hepatitis C virus after injuring herself on a needle used to take blood from an infected patient.
During the Health and Safety Executive (HSE) prosecution of Worcestershire Acute Hospitals NHS Trust over the February 2007 incident, City Magistrates heard the worker, who had been training at the Trust for three weeks, was instructed to take blood from a patient known to be infected with the virus.
After taking the sample, she had difficulty reaching the sharps bin to dispose of the needle, because other equipment surrounding the patient prevented access for her trolley.
Blood continued to seep through the patient’s dressing, so the worker placed the used needle on to the nearest work surface while she attended, but as she reached for a tissue to further dress the wound, she caught her wrist on the needle.
The HSE investigation found the employee was not made aware of the patient’s infection status until after the injury occurred and was not supervised during the procedure. Despite action to counter infection from the injury, she was subsequently diagnosed with symptoms of the virus.
An examination of the Trust’s system for taking blood samples from high-risk patients found failures to carry out suitable risk assessments where there was a risk of exposure to blood-borne viruses.
The Trust also failed to implement adequate controls or provide training around them, and lacked suitable arrangements for effective monitoring and review of safe working practices. HSE issued four improvement notices in May 2008 to address these issues, which the Trust subsequently complied with.
The Trust pleaded guilty to breaching Section 2(1) of the Health and Safety at Work etc. Act 1974 and Regulation 6 of the Control of Substances Hazardous to Health Regulations 2002 and was fined a total of £12,500 and ordered to pay £9,000 costs.
HSE inspector Jan Willets said:
“For staff regularly taking blood from patients, the risk of infection with the Hepatitis C virus from a contaminated needle is greater than for any other blood-borne virus.
“This infection was entirely preventable. The risks and controls are well known and the Trust should have had an effective safe system of work in place.
“It should have ensured an inexperienced healthcare worker was appropriately supervised, aware of the risks to her health from her work with this patient and the precautions to be taken.
“There are lessons for other Trusts who should check they have appropriate arrangements in place including identification of high-risk patients, using sharps disposal containers at the point of use, adequate supervision and training systems, and an implemented policy on the use of safer needles, devices and gloves.”
Source: HSE