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Remembering the Devonport Incident – 50 years on

One bottle is a killer. The other is entirely safe. They’re identical in every other way – indeed from the same manufacturing batch. This new acquisition was donated by Professor Barry Cookson, former Director of the Laboratory of Healthcare Associated Infection, HPA. But what happened to make one so deadly and the other not?

These are the first bottles of dextrose solution to be published ( Science Museum, London )

These bottles of dextrose are sad reminders of the life and death hunt for 500 similar bottles in March 1972. Five patients died at the Devonport Hospital in Plymouth having received fluid from the same batch as these. The fluid was found to be heavily contaminated with bacteria.  A landmark inquiry was launched to discover what went wrong and to ensure it wouldn’t happen again.

Sterilisation is a key story in the advancement of modern medicine. It’s critical to everyday hospital practice. Largely a practical matter of engineering and systematic checks, sterilisation isn’t glamorous but it’s critical for patient safety – as the Devonport Incident illustrated.

An autoclave is a machine that sterilizes equipment by subjecting them to high pressure steam ( Science Museum, London )

In 1971, these two bottles were autoclaved at the same time. A fault on the machine resulted in only the bottles on the top two shelves being sterilised properly. Those on the lower shelf were not. There were quality control checks – but the assessed bottles were only taken from the top shelf so the failure wasn’t detected and the whole batch was issued for use.

Eleven months later the bottles from the lower shelf reached Devonport hospital. During that time, surviving bacteria multiplied in the solution and produced a toxic fluid with deadly consequences.  There are only slight differences between the bottles – the aluminium cap on the contaminated bottle was still shiny as it hadn’t been sufficiently heated to go dull like the bottle that was sterilised

Image credit: Barry Cookson

 What’s sad is that it often takes tragic incidents like this to identify what’s going wrong with a system, and then implement new standards and checks. The inquiry identified numerous ways safety could be improved from manufacturer to hospital – thankfully those measures are still implemented today and the lessons from this incident are still taught to hundreds of healthcare workers every year.