WHEN patients began falling seriously ill with the bug Clostridium difficile at the Vale of Leven Hospital, in Dunbartonshire, their relatives had to watch.

Many say they felt powerless as their loved ones died in distressing and degrading circumstances, under the care of hospital staff who were struggling to cope.

The findings of the public inquiry into that outbreak, which started in January 2007, are the result of their determination to campaign for answers. With the full report running to 439 pages, the final result unveiled by inquiry chair Lord MacLean yesterday finally gives them a detailed pictured of where things went wrong:

Nurses

Patients and their relatives told the inquiry wards were short staffed and nurses were doing their best in difficult circumstances. Lord MacLean found staffing levels were generally acceptable, but became inadequate at times because of the number of patients who became seriously ill. Nevertheless, the inquiry uncovered a "catalogue of failures in fundamental aspects of nursing care". The report says these were not restricted to one ward, instead standards "had been permitted to lapse over a period of time".

The report says there was little evidence staff appreciated the seriousness of C. diff and fundamental aspects of treatment, including fluid and nutrition management, were not recognised.

Patients displaying symptoms of the infection were not isolated until NHS laboratories had confirmed C. diff was the problem, a practice described as "unsafe".

Basic details were often found missing from patients' admission assessments and care plans were poorly completed.

Between January 2007 and June 2008 there were two infection-control nurses based at the Vale. One did not have a qualification in infection control, but bore the brunt of duties as her senior colleague Jean Murray began a phased retirement in January 2008.

According to the report, Mrs Murray's perspective was that the number of C. diff cases could be explained by other factors than cross-infection on the wards. In the executive summary, Lord MacLean says: "The failure not to consider as a real possibility that the number of cases with CDI (C. diff) was a result of cross infection was inexplicable."

Doctors

The inquiry report says: "The medical staff seemed oblivious to the persisting CDI problem."

Recruitment to the hospital had become difficult as services had been cut and the future of key departments had been in doubt for some time. There were, apparently, no middle-grade doctors. Instead "a significant burden of managing patients was borne by junior doctors". The recording of patients' conditions by the junior doctors is described as "poor" in the report.

The need to be more careful about prescribing antibiotics to help reduce hospital infections had long been identified in Scotland, but Lord MacLean encountered real problems working out why some of the patients at the Vale were receiving antibiotics at that crucial time.

Concern about how often patients were given medical reviews is also raised by his report. It concludes: "The medical care of patients suffering from CDI was inadequate."

NHS Greater Glasgow and Clyde

The report says: "No doubt there were failures by individuals in relation to antibiotic prescribing and for the delays in the treatment of CDI patients, but the ultimate responsibility for standards having become unacceptable must rest with NHS GGC."

The health board had taken over the Clyde area including the Vale 18 months earlier. (Its health board had been scrapped with a financial black hole.) However, infection prevention and control policies in the Vale were not updated to match Glasgow. This was not given a high enough priority. Reporting structures which might have flagged-up the outbreak were inadequate and an opportunity to spot the extent of the problem which could have saved "a significant amount of suffering" was missed. Infection control committees failed to meet. Better systems would have spotted problems and that Dr Elizabeth Biggs, the infection control doctor for the Vale, was failing to carry out her duties.

Scottish Government

At that time there was no "effective inspectorate system" to check how well policies on controlling hospital bugs were being put into practice, something Lord MacLean describes as "surprising". He also criticises the Scottish Government for failing to learn lessons from C. diff outbreaks in England, which found strikingly similar problems to those which devastated patients and their families at the Vale.