This investigation was launched at the request of the Secretary of State for Health, following two serious outbreaks of Clostridium difficile at Stoke Mandeville Hospital, part of Buckinghamshire Hospitals NHS Trust.

Overall, 334 patients contracted the infection and at least 33 people died in the outbreaks, which took place between October 2003 and June 2005. These patients had acquired the infection while being treated in hospital.

The report highlighted serious failings on the part of senior managers at the trust, who failed to follow advice on stopping the spread of infection from infection control staff, clinicians, nurses and the Health Protection Agency.

Many factors had contributed to the outbreaks, including poor layout of older wards, inadequate cleaning, a lack of hand washing facilities and a lack of training in infection control. However, the primary factor was the failure to isolate patients with the infection.

More information

Further information on the investigation is available in the publications listed below:

• Investigation into outbreaks of Clostridium difficile at Stoke Mandeville Hospital
• Stoke Mandeville investigation progress report
• Action plan Bucks NHS Trust