Update on the independent serious incident investigation into the outbreak of invasive Group A Streptococcus (iGAS) in 2019

Briefing from Rachel Hearn, Director of Nursing & Quality for the Mid and South Essex CCGs Acute Commissioning Team and NHS Mid Essex Clinical Commissioning Group

Background recap

In February 2019 Public Health England identified an outbreak of invasive Group A Streptococcus bacterial infections (iGAS) in the mid and west Essex area.

39 people were affected, of whom 33 were confirmed as part of the iGAS outbreak, with a further 6 probable cases; 15 people sadly died.

Tests by Public Health England were able to identify the particular strain (emm44) and confirm that the cases were linked, leading to the understanding that this was an outbreak and not a series of isolated cases.

In January 2020, Mid Essex Clinical Commissioning Group along with partners involved in the incident management including Public Health England (PHE) and Provide Community Interest Company, took the decision to step down the Incident Management Team and some of the control measures that had been in place since March 2019. This was in line with criteria agreed in September 2019 by all organisations involved in the Incident Management Team.

Incident investigation

In July 2019 the Incident Management Team commissioned an independent serious incident investigation into the outbreak, in line with the NHS Serious Incident Framework.

The purpose of this independent investigation was to draw together the findings and learnings from those affected or involved in managing the incident, in order that steps may be taken to reduce the risk of reoccurrence. Those interviewed included families of patients who had sadly passed away and representatives from organisations involved in patient care and incident management.

Publishing the report

The independent investigation has now been completed and the initial draft report covering the findings has been prepared.

As you will be aware, we now find ourselves in unprecedented times due to the impact of the COVID-19 (Coronavirus) outbreak. It is a global crisis affecting each and every one of us and so all staff in the NHS including Mid Essex Clinical Commissioning Group and West Essex Clinical Commissioning Group are focused on supporting the response to this.

We have had to make some difficult decisions in order that we can prioritise where our NHS resources are focused; for the foreseeable future that has to be on COVID-19 (Coronavirus). Therefore, we will be delaying the publication of the iGAS independent investigation report until the NHS has started to recover from the impact of the COVID-19 (Coronavirus) outbreak.

Although publishing the report has been delayed, we have already taken steps to help us avoid the likelihood of an iGAS outbreak happening again. We will not let the delay stop us making improvements that can be actioned now, based on what we have already learned from the outbreak (appropriate infection protection measures have also been stepped up as a result of COVID-19 (Coronavirus).

We have also been in touch with the individuals and their families affected by the iGAS outbreak to make them aware of the delay and a commitment that we will be in touch with them again as soon as possible to update them.

What happens next?

As we have stated above, our priority is to focus all of our resources on COVID-19 (Coronavirus) for the foreseeable future.

We will inform all stakeholders of the expected publication date for the report in due course.

Any enquiries regarding this update should be emailed to MECCG.Communications@nhs.net

Thank you for your patience and understanding.