MEDICAL experts in Nottingham have spent much of the last year trying to discover how routine surgery at City Hospital led to patients contracting a fatal infection.

Eleven patients are known to have contracted endocarditis after being fitted with a prosthetic heart valve at the Trent Cardiac Centre.

Five of them died.

Action was only taken to stop the outbreak on July 13, last year, when medics linked the cases to one surgeon.

But a investigation launched by the trust which runs Nottingham's hospital has now concluded there was enough information for action to have been taken nearly two months earlier, on May 23.

It said three of the cases, including one of a patient who died, could have been avoided if something had been done at that time.

A full inquest into four of the five deaths, which took place in Nottingham, is not expected to take place until November.

Further evidence could be presented before Notts coroner Dr Nigel Chapman makes an official ruling on how the deaths came about.

The internal report ordered by Nottingham University Hospitals NHS Trust – the trust which runs the City Hospital – is not due to made public until after the inquest has taken place.

However, a copy has been seen by the Post.

Its authors said they were "concerned" and "disturbed" by incidents where information about the outbreak was not passed on.

In one, doctors became aware of at least two cases of endocarditis at the trust but did not pass them on to a microbiologist or an infection control doctor.

And the results of a heart scan for a patient, who later died from the infection, were not passed on, meaning a chance to diagnose their illness was missed.

All the patients affected had heart valve operations at the hospital's Trent Cardiac Centre with the same surgeon.

Bacteria was passed from the surgeon and caused a staphylococcal – or blood stream – infection that led to inflammation around the heart valve, according to the report.

The report said: "Opportunities were missed to identify the outbreak earlier than July 13 because of a lack of shared information or suspicions.

"Some of the cases might have been avoided by earlier recognition of the connection between cases in which endocarditis was suspected by clinicians."

It added: "It can be difficult to know when a series of isolated cases represents an outbreak.

"[But] the panel is concerned that lack of communication meant opportunities were missed to make connections and to flag these infections earlier as an outbreak."

"There are concerns also that opportunities may have been missed to have diagnosed endocarditis earlier in individual cases, where treatment might have had a greater chance of success."

Hospital bosses admit their communications systems did not work well enough for information about infection outbreaks to be shared.

They say individual workers were not to blame and that their "processes" have since been strengthened to better detect infection outbreaks.

The surgeon who operated on all the affected patients has since stopped performing surgery of any kind to avoid further cases.

The report said there was "no evidence of shortcomings in his infection prevention and control techniques".

But the antibiotic strain of the bacteria remains on his skin, despite efforts to get rid of it.

The report's authors, which included a top microbiologist at the trust, said they could not find a "failure of normal good practice" which might have caused the outbreak.

But measures, such as changing the antibiotics used have meant that no further cases have been reported since last July.

Among the patients who died as a result of the infection was Thomas Cooper, an 82-year-old, from Long Eaton.

The grandfather-of-three contracted prosthetic valve endocarditis from a strain of bacteria that got into his system during surgery.

Mr Cooper never fully recovered after being operated on in December 2008 and died in hospital at Derby, in May.

Nurse Dorothy Brown, 68, of Beeston, nearly died after contracting the infection following heart valve surgery.

She has since suffered short-term memory loss and has decided to take herself off the nursing register to avoid endangering patients.

Her MP Anna Soubry recently put out an appeal for other victims to come forward to help her bid for compensation.

She said: "Dorothy could have been diagnosed with having the infection earlier, which might have reduced her suffering.

"A lot of my constituents are treated at City Hospital, if someone is infected it is important to all of us that it is detected quickly."

Mrs Brown is attempting to get compensation for her experience alongside other victims and their families.

Some are being represented by Irwin Mitchell solicitors and others by Freeth Cartwright.

Julie Hardy, a partner at Freeth Cartwright, said: "In view of the inquiry's findings, we are keen to work with the trust and their legal representatives to ensure that our clients are properly compensated.

"We are confident that this can be achieved without the need for litigation as we are keen to avoid further distress to our clients."