BSE, CJD and OPs

24 patients at risk through non-application of guidelines on use of surgical instruments. When a patient who had undergone operation at Middlesbrough General Hospital became a sporadic CJD suspect the instruments should have been put into immediate “quarantine” as normal sterilization is not 100% effective in destroying the infective prion agents. However, they remained in use with infection risk to 24 other patients throughout the period of test and investigation of the primary patient.