Maidstone and Tunbridge Wells NHS Trust

The UK Healthcare Commission has asked the Health and Safety Executive and Kent Police to investigate Maidstone and Tunbridge Wells NHS Trust, following the death of nearly 350 people infected with the Clostridium difficile bacterium in three hospitals between 2004 and 2006.

The Commission's report suggests poor hygiene, staff shortages and a preoccupation with government targets contributed to the Trust's failure to manage spread of the bacteria.

This will come as no surprise to anyone who visited the Accident and Emergency Unit at Maidstone Hospital (one of the three hospitals involved) during that period. I had cause to go there (not, fortunately as a patient) in December 2005, right in the middle of the C diff outbreak. No one then can have been unaware of the risks and the need for the highest standards of hygiene - MRSA and C diff were filling the local and national press and people were afraid to go into hospital in a way that they had not been since early victorian times.

It was therefore all the more incredible that, during the inevitable three or four hour delay between triage and treatment, patients and visitors found that the lavatories serving the unit were in a disgusting and unhygienic state. This, mark you, in an area where there were patients with open wounds, breathing difficulties and a variety of other conditions which may have made them more susceptible to infection.

Throughout the period that people waited, scared and unwell, for someone to arrive and offer treatment, there were half a dozen nurses seated at desks, chatting, drinking coffee and tapping at computer keyboards in an environment more like an office than a treatment centre. I am not implying blame here; no doubt they were filling in forms for monitoring government targets. But they did seem to illustrate in the most graphic way the shift from patient care to bureaucracy.

The Trust's chief executive, Rose Gibb, resigned last week. Kent Police and the HSE will now consider whether charges should be brought.