The Chief Medical Officer has ordered an inquiry into how some patients were exposed to the risk of contracting CJD from surgical instruments.

Twenty-four patients at a Teesside hospital may have been infected with the fatal brain disease "sporadic" CJD.

Twenty-two have now come forward, but a special call centre set up by Middlesbrough General Hospital received around 150 calls from worried patients.

The instruments were previously used on a woman diagnosed with the fatal brain disease.

It's possible it could happen again tomorrow

Dr Paul Lawler, South Tees NHS Trust

The patients are being informed that there is a very small risk that they may have been exposed to the condition.

The equipment was not decontaminated properly after being used for a brain biopsy in July at Middlesbrough General Hospital.

CJD was only diagnosed two weeks later.

The hospital is contacting those at risk this week, and will tell them there is a very small chance of them contracting CJD. A helpline is also being set up.

The hospital said it did follow official guidelines on when instruments should be removed from use.

But it admitted to the BBC that it had not fully implemented rules on identifying and tracking surgical instruments issued three years ago.

South Tees NHS Trust medical director Dr Paul Lawler warned: "It's possible it could happen again tomorrow, in this hospital or in any other hospital."

Common procedure

The Department of Health said: "The Middlesbrough General Hospital found itself in a very difficult situation in that there was no clinical suspicion of CJD.

"Clinical suspicion of CJD is the normal trigger for quarantining instruments on a precautionary basis.

But the trust is maintaining that CJD was not suspected when the biopsy, a common surgical procedure, was carried out.

This incident should never have happened

Gill Turner, CJD Support Network

They have suggested it was only the "due diligence" of a pathologist that allowed the disease to be diagnosed.

Dr Lawler said the woman at the centre of the scare was examined by five neurologists, with no suggestion of CJD prior to the operation.

He said: "The patient was not suspected of having this particular illness and, as a result, we did not quarantine the instruments straight away."

He said the patient had an illness in which there was memory loss. The pattern of illness was not that of CJD.

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Dr Lawler admitted that "in hindsight" it may have been better to have removed the instruments immediately, rather than waiting until the diagnosis had been confirmed.

He added that patients had been contacted as soon as it was known who was at risk.

"Twenty four patients are at a very small risk of contracting CJD of the 29 who could have been."

He said there had only been five cases of CJD transmission from neurosurgical operations.

But he stressed the rules on the removal of surgical instruments had been adhered to: "We followed guidelines issued by the Department of Health, and in place at this hospital, to the letter."

Incubation period

But the Department of Health said the instruments should have been quarantined as soon as the risk of CJD was evident, and not once it had been confirmed, at which point such instruments are completely withdrawn from use.

Dr Paul Lawler: 'Guidelines were followed'

Dr Evan Harris, Liberal Democrat health spokesman, said: "The guidance could have been clearer and said that whenever a test for CJD is being carried out, the instruments should be quarantined."

The strain of the illness involved is sporadic CJD - which is not linked to eating beef from a BSE-infected cow.

Sporadic CJD accounts for around 85% of all cases of the illness and can have an incubation period of up to 20 years.

Although the Middlesbrough patients' risk of contracting the disease is said to be miniscule, there is no easy test to diagnose it and it is incurable.

Gill Turner, medical co-ordinator of the CJD Support Network, told the BBC: "This incident should never have happened.

"There are very clear guidelines for CJD and, by definition, because this person was having a brain biopsy, CJD must not have been ruled out."

She added: "If I was one of those 24 people, what would I be able to do?

"It's devastating news, and they can stress that it's only a theoretical risk, but if you've been told that you've even been put at risk, it would affect the rest of your life."

What is your reaction to this latest news about CJD? We will be discussing the subject in our interactive forum for the Six O'Clock News at 1830 tonight. If you have any questions to ask our expert, use the postform below to send them.

I think that these days all equipment should be used once and then thrown away. Especially these days with the risk of illnesses such as CJD, Hepatitis, AIDS, HIV etc. If it costs more money then so be it.
Tamzin Stringer, England

This is pure scaremongering. There is no doubt that the NHS are in somewhat of a mess but we should be at least grateful that we have the NHS system rather than something similar to that in the States where, if you can't afford treatment you have to go without! Stop giving the Hospitals and their hardworking staff such a hard time!
Jenni, England

What are the usual sterilization procedures, as opposed to those for suspected CJD?. If the usual sterilization procedures of the instruments where followed, how resistant is CJD to these procedures.? Finally what other sterilization would the instruments go through had CD been suspected initially?
Isaac, UK

What is being done to support these 24 people, who have just been told that they might have an undetectable, devastating, incurable, terminal disease that won't show any symptoms for decades. How are they supposed go on with their lives with that hanging over them?
Kelli, UK

Why didn't the hospital fully implement the rules on identifying and tracking surgical instruments? These rules have been around a long time and are there for obvious reasons. What measures can we expect to be taken against the hospital and any individuals responsible for this neglect of duty? And what connotations does this have on other hospitals?
Richard, UK

My son died from variant CJD in February 2000. Paul Lawler of the Middlesbrough Hospital is quoted as saying that due to the diligence of a pathologist, a sample was sent to the CJD surveillance unit to rule out CJD rather than confirm it. This must surely mean that a responsible member of hospital staff suspected that CJD might be possible. No action was taken until CJD was confirmed Common sense dictates that it is sensible in these circumstances to quarantine the suspect instruments until CJD is or is not confirmed.
Ron Carter, England

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