Incomplete sterilisation of equipment

On Monday 11 February the Hawke’s Bay District Health Board discovered that a batch of equipment used in the hospital operating theatres and community settings had been dispatched without completing the full sterilisation process.

While this batch of equipment was properly cleaned, heated to a very high temperature and dried, the final sterilisation process was not completed as it should have been and therefore may pose an infection risk to patients that came into contact with the equipment. A large proportion of the equipment in the batch has been located and withdrawn without being used.

We know the batch that missed this process, who the equipment was used on and have already contacted the majority of people at highest risk.

Our incident management team has consulted with local and national experts from the institute of Environmental Science and Research (ESR) as well as our own infectious disease specialist Dr Andrew Burns. They have provided reassuring advice that the likelihood of patients becoming exposed to infection is extremely remote and highly unlikely.

Anyone who is concerned should call the Hospital Call Centre on 06 878 8109 and ask to be put through to the person dealing with the incomplete sterilisation.

Understandably the DHB is seeking answers as to how this system and process failure occurred and we have launched an investigation which will be externally reviewed to understand how this happened.

The DHB unreservedly apologises for any distress this has caused. We would like to reassure the public of the expert scientific advice we have received, how small the risk of infection is, and encourage anyone concerned to contact us via the call centre if they believe they are affected.

We will continue to be open and transparent as we work through this process.

On Wednesday 13 February a media conference was held with various news outlets speaking to CEO Dr Kevin Snee, Executive Director Provider Services Dr Colin Hutchison, Medical Officer of Health Dr Nick Jones, and Surgical Head of Department Dr Sud Rao. You can watch Radio New Zealand's video footage of the conference here