In 2008, the Nanaimo Regional General Hospital (NRGH) experienced a deadly outbreak of C. difficile infections. It was an outbreak waiting to happen. All the warning signs were there. Little attention was paid to them or little cash available to address them.

To get a sense of what happened and how, one needs to go back to 2003, when the rate of C. difficile infections at the NRGH jumped.

Staff came up with an eight-point plan to address the infection and rates dropped. Dramatically so.

But no one knew much about it. The results of the review, the actions taken, and what to do next were never shared across the Vancouver Island Health Authority.

Something else happened in 2003: cleaning responsibilities at the NRGH were privatized and contracted out. It was going to play a role in the outbreak.

VIHA's own assessment—undertaken by its environment team in 2005—“identified several major risk areas that urgently needed to be addressed, including infection control.”

Also of note from 2005: the day after the B.C. election, ministry officials warned health authorities “not to put sensitive information in writing” to prevent the NDP and others from accessing that information via legislation.

VIHA media advisor Suzanne Germain passed the edict on in an email to key staff: “use the phone a lot more than we have been. If you don't want it on the front page of (the Times Colonist), don't put it in an E mail..."

Ironically enough, Germain's email was leaked to Sean Holman's Public Eye Online.

Secrecy had gained some favour at VIHA.

In a February 2006 report, staff at the Capital Regional District wrote: “Experience suggests that VIHA is not transparent and open to the public or key stakeholders.”

There were two more upticks in C. difficile infections at the NRGH, in 2005 and 2006, but not enough to cause much pause among officials.

An automated system for cleaning bedpans was installed, but they didn't work particularly well. Each cycle took 13 minutes, during which time they couldn't be left unattended since the same bedpan had to be returned to the same patient. The nursing staff hadn't been consulted on the purchase.

Then it was the B.C. auditor general's turn in his 2007 report, “Infection Control: Essential for a Healthy British Columbia. His conclusion? “VIHA has no comprehensive, integrated infection control program yet in place. While the health authority has recognized the need to determine its status in infection prevention, surveillance and control, it has much to do.”

The report also noted that “Because many of the facilities in (VIHA) are older, there are not adequate hand washing sinks in appropriate places.” That too was going to play a role in the outbreak.

It was a retired nurse—Jeannie Whitfield—who sounded the alarm next.

Whitfield—a carrier of the MRSA superbug and who had been a recent patient at the NRGH—went public in January 2008 with her concerns over infection control practices.

Lesley Moss, executive director of patient safety at VIHA, brushed off Whitfield's concerns, "I apologize that she feels the staff don't take it seriously but my experience is the staff take it very seriously."

Within months, a major outbreak of C. difficile struck the NRGH.

The B.C. Centre for Disease Control reported 64 cases of C. difficile infections and five deaths between June and August 2008.

But the Centre for Disease Control had a second mission at the NRGH: identify the key factors that led to the outbreak.

Among their findings: the NRGH is an older facility that wasn't well constructed to prevent infection, it operated over capacity on a continuous basis, and there was only one handwashing sink on each floor.

And remember that 2003 contracting out of cleaning services?

In its report, the Centre noted that “there was a shortage of cleaning staff and those that were available hadn't been adequately trained in cleaning procedures for a healthcare facility.”

In 2009, the Nanaimo Daily News reported that VIHA delayed the release of the report, so as to "temper" the impact it would have on the public.

Spokesperson Suzanne Germain told the Daily News that there was no attempt to control the message and that the health authority had every intention to release it.

Despite VIHA's 2005 assessment that had identified infection control as a major risk facing the authority and the B.C. auditor general's 2007 conclusion that VIHA had “no comprehensive, integrated infection control program yet in place,” VIHA's CEO Howard Waldner didn't refer to either in his 2009 summer update to staff.

Instead he focused on the fact that VIHA had asked its chief medical health officer Dr. Richard Stanwick to make recommendations on “how VIHA could improve systems and processes around responding to in-hospital outbreaks throughout the health authority.”

The NRGH had 15 more cases of C. difficile infection in late 2009 and 49 more from March to August 2010. Three deaths were attributed to the outbreaks.

All this gleaned from the documents—internal and public—that exist.

But Suzanne Germain's 2005 email raises a thornier question: what “sensitive information” was never put down in writing on the instructions of B.C.'s health ministry?