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Sigmoidoscope contaminated with blood of previous patient (01HDC01818)

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(01HDC01818, 24 September 2002)

Public hospital ~ Contaminated equipment ~ Infection control ~ Hospital protocols ~ Rights 4(1), 4(4)

A patient complained that a sigmoidoscope used on him was contaminated by a previous patient's blood.

The Commissioner reasoned that:

1) it is axiomatic that any patient who is being treated or investigated with any piece of medical equipment should expect that the equipment is clean and not soiled with bodily fluids from another patient;
2) the public hospital policy manual should have either dealt with the cleaning of sigmoidoscopes specifically, or contained a generic policy that dealt with all "hollow tube" investigation devices, yet there were no policies, protocols or guidelines for cleaning the equipment at the time of the incident; and
3) the staff members involved were effectively victims of a systems error that resulted from a lack of guidance by the public hospital.

It was held that the public hospital breached Rights 4(1) and 4(4) because the absence of an appropriate policy to cover the use and cleaning of sigmoidoscopes amounted to a failure to provide services with reasonable care and skill and in a manner that minimised potential harm to the patient.

No recommendations were made in light of the prompt and appropriate action the hospital had already undertaken, in particular by apologising to the patient and developing and implementing procedures to prevent a recurrence.



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