SGH Hep C Timeline

SGH

Three more cases test positive for Hep C

Approx. April 27, 2015 - May 14, 2015

Total positive cases from lab testing: 4.

Review of SGH Dialysis Centre

May 14, 2015

SGH Renal team initiates review of SGH Dialysis Centre.

Results from review of SGH Dialysis Centre

Approx. May 29, 2015

Conclusion that Hep C transmission in cluster not related to process in centre.

SGH's Division Chair of Medicine is informed

Approx. May 30, 2015

SGH's Division Chair of Medicine is informed. Around this time, the total number of cases tested positive by the laboratory rises to 7.

Director of Infection Control is informed

Approx. June 3, 2015

Preliminary investigation by SGH Infection Control

Approx. June 5, 2015 - Approx. June 8, 2015

Preliminary epidemiological investigation by SGH Infection Control and infection control measures instituted.

Cessation of multi-dosing in Renal Ward

Approx. June 9, 2015

SGH lab conducts literature review

Approx. June 9, 2015 - Approx. June 22, 2015

SGH laboratory conducts literature review and planning for gene sequencing study.

9 new cases tested positive by laboratory

Approx. June 18, 2015 - Approx. June 30, 2015

Cessation of multi-dosing in all wards

June 24, 2015

Frequent audits by Infection Control team

June 24, 2015 - July 23, 2015

SGH lab generates first phylogenetic tree

July 3, 2015

SGH laboratory generates the first phylogenetic tree based on polymerase region.

SGH Clinical Governance enquires with SGH Renal

July 10, 2015

SGH Clinical Governance enquires with SGH Renal on the Hep C Cases and states that it may need to be escalated to Group CEO (GCEO), Group Chief Risk Officer (GCRO) and Office of Risk Services (ORS).

Phylogenetic analysis of first 20 cases confirm cases are related

July 29, 2015

Phylogenetic analysis of first 20 cases is completed, confirming cases are related.

Finalise findings and reports for updating CEO, and briefing GCEO and MOH

Approx. August 1, 2015 - Approx. August 31, 2015

Finalise findings and reports from nursing, hepatology and infection control in preparation for updating CEO, and briefing GCEO and MOH. Work on treatment recommendations, patient assistance, and communications plan.

CEO, CMB and Division Chair of Medicine meet

Approx. August 18, 2015

CEO, Chairman of the Medical Board (CMB) and Division Chair of Medicine meet and plan for open disclosure to affected patients (awaiting completion of investigative findings), and to update Group CEO and MOH - CMB decides that it is better to do a face-to-face meeting with MOH.

CMB decides to add more controls and samples for phylogenetic study

Approx. August 24, 2015

CMB decides to add more controls and samples to increase the assay confidence for phylogenetic study.

Preliminary A*STAR report largely concurs with SGH Lab findings

Approx. September 7, 2015

Preliminary A*STAR report largely concurs with SGH Laboratory findings.

Medical Review Committee reviews the 7 mortalities. Staff screening begins

Approx. September 9, 2015

Medical Review Committee convenes a meeting to review the 7 mortalities. Staff screening commences.

Report of incident to SingHealth Board

Approx. September 20, 2015

Quality Assurance Committee convenes meeting

September 23, 2015

Medical Review Committee meets to review 8th mortality case

October 8, 2015

MOH

HSD informs CDD and CQPT, requests for CDD's follow-up

Approx. June 4, 2015

HSD informs Communicable Diseases Division (CDD) and Clinical Quality, Performance & Technology Division (CQPT), requests for CDD's follow-up.

NOTU notifies HSD and CDD of a new case

Approx. June 11, 2015

NOTU notifies HSD and CDD of a new case, and asks CDD if SGH transplant activity should be suspended.

CDD notifies CQPT and asks that CQPT follow up

Approx. June 18, 2015

Director of Medical Services is informed by MOH staff

September 1, 2015

Director of Medical Services (DMS) is informed by MOH staff.

DMS is updated by CQPT on SGH's progress

September 17, 2015

DMS is updated by CQPT on SGH's progress: Renal transplant was suspended, with arrangements made with other hospitals; Medical Review Committee had met on September 9; and Quality Assurance Committee was intending to meet on September 23.

Minister of Health is informed

September 18, 2015

SGH and MOH

SGH reports one Hep C infection case to NOTU

Approx. April 27, 2015

Singapore General Hospital (SGH) reports one Hepatits C (Hep C) infection case to National Organ Transplant Unit (NOTU).

HSD is copied in the email correspondence

Approx. May 26, 2015

NOTU suggests to SGH Renal that it should report to infection control physician for tracing of source of potential infection, and Hospital Services Division (HSD) is copied in the email correspondence. SGH Renal informs that it is already looking into the matter and it could be due to the switch to a more sensitive testing method.

SGH CEO given verbal briefing, CQPT contacts SGH Renal

Approx. June 19, 2015

SGH CEO is given a verbal briefing about the cluster. CQPT contacts SGH Renal to ask about the six reported cases.

SGH Renal informs CQPT of on-going investigation

Approx. June 21, 2015

SGH Renal informs CQPT that investigation is in progress

CQPT requests that SGH Clinical Governance follow up and report on Hep C cases

June 23, 2015

CQPT requests that SGH Clinical Governance follow up and report on Hep C cases, and informs that it is reportable as a serious reportable event (SRE).

CQPT makes follow-up enquiry with Renal Unit

July 30, 2015

Division Chair of Medicine proposes face-to-face meeting with MOH

August 28, 2015

Preliminary SGH findings are shared with MOH staff

August 31, 2015

DMS meets SGH

September 3, 2015

MOH team visits SGH

September 4, 2015

DMS meets CMB to affirm plans

September 8, 2015

Submission of SGH investigation report to DMS

September 24, 2015

SGH briefs Minister of Health

September 25, 2015

Extended staff screening begins within SGH. MOH appoints Independent Review Committee

September 28, 2015

Start of extended staff screening within SGH. MOH appoints members of Independent Review Committee.

SGH reports 8th death

September 30, 2015

SGH holds media briefing, MOH releases Press Statement

October 6, 2015

SGH holds media briefing. MOH releases Press Statement on convening the Independent Review Committee, its members and the terms of reference.

All Events

Three more cases test positive for Hep C

Approx. April 27, 2015 - May 14, 2015

Total positive cases from lab testing: 4.

SGH reports one Hep C infection case to NOTU

Approx. April 27, 2015

Singapore General Hospital (SGH) reports one Hepatits C (Hep C) infection case to National Organ Transplant Unit (NOTU).

Review of SGH Dialysis Centre

Approx. May 14, 2015

SGH Renal team initiates review of SGH Dialysis Centre.

HSD is copied in the email correspondence

Approx. May 26, 2015

NOTU suggests to SGH Renal that it should report to infection control physician for tracing of source of potential infection, and Hospital Services Division (HSD) is copied in the email correspondence. SGH Renal informs that it is already looking into the matter and it could be due to the switch to a more sensitive testing method.

Results from review of SGH Dialysis Centre

Approx. May 29, 2015

Conclusion that Hep C transmission in cluster not related to process in centre.

SGH's Division Chair of Medicine is informed

Approx. May 30, 2015

SGH's Division Chair of Medicine is informed. Around this time, the total number of cases tested positive by the laboratory rises to 7.

Director of Infection Control is informed

Approx. June 3, 2015

HSD informs CDD and CQPT, requests for CDD's follow-up

Approx. June 4, 2015

HSD informs Communicable Diseases Division (CDD) and Clinical Quality, Performance & Technology Division (CQPT), requests for CDD's follow-up.

Preliminary investigation by SGH Infection Control

Approx. June 5, 2015 - Approx. June 8, 2015

Preliminary epidemiological investigation by SGH Infection Control and infection control measures instituted.

Cessation of multi-dosing in Renal Ward

Approx. June 9, 2015

SGH lab conducts literature review

Approx. June 9, 2015 - Approx. June 22, 2015

SGH laboratory conducts literature review and planning for gene sequencing study.

NOTU notifies HSD and CDD of a new case

Approx. June 11, 2015

NOTU notifies HSD and CDD of a new case, and asks CDD if SGH transplant activity should be suspended.

CDD notifies CQPT and asks that CQPT follow up

Approx. June 18, 2015

9 new cases tested positive by laboratory

Approx. June 18, 2015 - Approx. June 30, 2015

SGH CEO given verbal briefing, CQPT contacts SGH Renal

Approx. June 19, 2015

SGH CEO is given a verbal briefing about the cluster. CQPT contacts SGH Renal to ask about the six reported cases.

SGH Renal informs CQPT of on-going investigation

Approx. June 21, 2015

SGH Renal informs CQPT that investigation is in progress

CQPT requests that SGH Clinical Governance follow up and report on Hep C cases

June 23, 2015

CQPT requests that SGH Clinical Governance follow up and report on Hep C cases, and informs that it is reportable as a serious reportable event (SRE).

Cessation of multi-dosing in all wards

June 24, 2015

Frequent audits by Infection Control team

June 24, 2015 - July 23, 2015

SGH lab generates first phylogenetic tree

July 3, 2015

SGH laboratory generates the first phylogenetic tree based on polymerase region.

SGH Clinical Governance enquires with SGH Renal

July 10, 2015

SGH Clinical Governance enquires with SGH Renal on the Hep C Cases and states that it may need to be escalated to Group CEO (GCEO), Group Chief Risk Officer (GCRO) and Office of Risk Services (ORS).

Phylogenetic analysis of first 20 cases confirm cases are related

July 29, 2015

Phylogenetic analysis of first 20 cases is completed, confirming cases are related.

CQPT makes follow-up enquiry with Renal Unit

July 30, 2015

Finalise findings and reports for updating CEO, and briefing GCEO and MOH

Approx. August 1, 2015 - Approx. August 31, 2015

Finalise findings and reports from nursing, hepatology and infection control in preparation for updating CEO, and briefing GCEO and MOH. Work on treatment recommendations, patient assistance, and communications plan.

CEO, CMB and Division Chair of Medicine meet

Approx. August 18, 2015

CEO, Chairman of the Medical Board (CMB) and Division Chair of Medicine meet and plan for open disclosure to affected patients (awaiting completion of investigative findings), and to update Group CEO and MOH - CMB decides that it is better to do a face-to-face meeting with MOH.

CMB decides to add more controls and samples for phylogenetic study

Approx. August 24, 2015

CMB decides to add more controls and samples to increase the assay confidence for phylogenetic study.

Division Chair of Medicine proposes face-to-face meeting with MOH

August 28, 2015

Preliminary SGH findings are shared with MOH staff

August 31, 2015

Director of Medical Services is informed by MOH staff

September 1, 2015

Director of Medical Services (DMS) is informed by MOH staff.

DMS meets SGH

September 3, 2015

MOH team visits SGH

September 4, 2015

Preliminary A*STAR report largely concurs with SGH Lab findings

Approx. September 7, 2015

Preliminary A*STAR report largely concurs with SGH Laboratory findings.

DMS meets CMB to affirm plans

September 8, 2015

Medical Review Committee reviews the 7 mortalities. Staff screening begins

Approx. September 9, 2015

Medical Review Committee convenes a meeting to review the 7 mortalities. Staff screening commences.

DMS is updated by CQPT on SGH's progress

September 17, 2015

DMS is updated by CQPT on SGH's progress: Renal transplant was suspended, with arrangements made with other hospitals; Medical Review Committee had met on September 9; and Quality Assurance Committee was intending to meet on September 23.

Minister of Health is informed

September 18, 2015

Report of incident to SingHealth Board

Approx. September 20, 2015

Quality Assurance Committee convenes meeting

September 23, 2015

Submission of SGH investigation report to DMS

September 24, 2015

SGH briefs Minister of Health

September 25, 2015

Extended staff screening begins within SGH. MOH appoints Independent Review Committee

September 28, 2015

Start of extended staff screening within SGH. MOH appoints members of Independent Review Committee.

SGH reports 8th death

September 30, 2015

First meeting of Independent Review Committee

October 5, 2015

SGH holds media briefing, MOH releases Press Statement

October 6, 2015

SGH holds media briefing. MOH releases Press Statement on convening the Independent Review Committee, its members and the terms of reference.

Medical Review Committee meets to review 8th mortality case

October 8, 2015