All this, due to sloppy handling of equipment by staff at Singapore General Hospital.
That was the finding of the Independent Review Committee, tasked with investigating the outbreak which was covered up for months before word spread to the Ministry of Health, and Singapore’s Health Minister.
18 spot checks found that staff were lax with the hygiene, and the handling of contaminated equipment.
The committee also found that there were gaps in infection prevention and control practices, failure by SGH to recognise the outbreak, and delays in notifying the higher-ups in the hospital as well as the MOH.
Multi-dose vials was found to be a possible cause of the infection, but not the sole source of transmission as not all affected patients had used them.
Meanwhile, police have ruled out foul play as the cause of the outbreak.
The committee’s findings come as no surprise.
A look at the timeline between discovering and reporting the infections alone shows the sloppiness of SGH’s procedures.
Others have complained that SGH hid news of the infections from patients.
SGH has apologised to those affected and said it will learn from the experience.