Health Board apologises after Vale of Leven Hospital C.diff deaths inquiry finds systemic failures

It revealed C.diff was a factor in the death of 34 out of 143 patients who had tested positive for the infection at the hospital during the period January 1 2007 to December 31 2008.

Inquiry chairman Lord MacLean said the true figure could be higher still, as medical records were not available for all the patients who died during the period.

He published his report - which makes a total of 75 recommendations - and said: "Patients at the Vale of Leven Hospital were badly let down by people at different levels of NHS Greater Glasgow and Clyde who were supposed to care for them. There were failures by individuals but the overall responsibility has to rest with the health board.

"The Scottish ministers bear ultimate responsibility for NHS Scotland and, even at the level of the Scottish Government, systems were simply not adequate to tackle effectively a healthcare-associated infection like CDI.

"The major lesson to be learned is that what happened at Vale of Leven Hospital to cause such personal suffering should never be allowed to happen again."

Shona Robison, who was appointed Health Secretary on Friday, said the Scottish Government accepted all of the report's recommendations.

She said: "Our first thoughts must be with the families and patients who have been let down by our NHS and for that I am truly sorry."

Ms Robison pledged: "Our top priority is that lessons are learned so that what happened at the Vale of Leven can never be allowed to happen again."

Andrew Robertson, chairman, of NHS Greater Glasgow and Clyde, said: "On behalf of the board and our staff, I would like to offer a full and unreserved apology to the patients affected and to the families who lost a relative to C.diff in the months between January 2007 and late 2008.

"This was a terrible failure and we profoundly regret it.

"I can give the firmest of assurances that, as a result of the lessons that have been learned, this could not happen again."

Lord MacLean said C.diff could be a "devastating illness, particularly in the frail and elderly", and added that "deficiencies" in medical and nursing care at the hospital "seriously compromised the care of this group of patients".

Infection prevention and control practices were "seriously deficient", with Lord MacLean saying "unacceptable levels of care discovered were not the levels of care which I would have expected to find in any hospital in Scotland".

Staff at the Vale of Leven did not identify C.diff as being a problem between January 2007 and May the following year, he said, "even although a significant number of patients suffered from the illness during that period".

Lord MacLean said while nurses at the hospital "may have been doing their best" there were "individual failures caused by a number of factors, including pressures of work, lack of training and inadequate support".

He added: "Poor leadership also contributed to an inadequate standard of nursing care."

He condemned as "totally unacceptable" delays in patients starting treatment for C.diff after ward staff became aware they had tested positive for the infection.

He also said that for many of the patients concerned, "there was no evidence that a proper clinical assessment of the patient's condition had been made".

The report stated: "Overall it is likely that patient care was compromised by the inadequate standard of medical care."

There was also criticism of Dr Elizabeth Biggs, the infection control doctor at the hospital, with the report describing her attitude to her role as "wholly inappropriate and professionally unacceptable".

It added that it was "surprising and indeed regrettable" that an effective hospital inspection system had not been put in place before June 2008, with Lord MacLean branding this a "failure on the part of the Scottish Government".

Ministers and the health board also paid "inadequate attention" to other outbreaks in the UK, which had already identified problems similar to those at the Vale of Leven.

The report highlighted poor practice in antibiotic prescribing at the hospital, saying: "There were instances of antibiotics being prescribed when no antibiotic was necessary."

Here he said there were two "targets for criticism" - NHS Greater Glasgow and Clyde for "failing to respond to the messages being sent on the importance of prudent prescribing" and also the Scottish Government for failing to identify and remedy this.

Lord MacLean said many of the families of those affected were critical of the poor levels of communication with staff at the hospital, stating: "Some relatives were told that it was a 'wee bug'. That is not an apt description of what can be a life-threatening infection."

The families of those affected by the C.diff outbreak had mounted a sustained campaign for a public inquiry into what happened.

Many of them were present as Lord MacLean published his report at the Royal College of Physicians and Surgeons in Glasgow today.

Lawyer Patrick McGuire from Thompsons Solicitors, who represents many of the victims' families, said it had been an "emotional and difficult time for the families" as they had confronted "the failings in care for their own loved ones".

He added: "They have had to confront why they have needlessly lost family members and would ask that everyone gives them the time to grieve and to put the report into that context."

Mr McGuire read a statement from the families that said: "As a group we comprise those who still grieve for loved ones and also those who continue to suffer the terrible effects that they contracted during this outbreak.

"There are no words that we can say to you today that will accurately reflect the anger, the hurt and the grief that we have felt over the past seven years, for the suffering that our loved ones had to endure as they succumbed to this terrible outbreak.

"Many of us watched, powerless, as our dearly loved family members died in distressing and degrading circumstances as hospital staff struggled to cope.

"We've reached a stage today where Lord MacLean has identified many causes of the outbreak and has made recommendations that we sincerely hope mean that no other families will suffer the hell that we have been through."

Mr McGuire said the relatives would "continue fighting to make sure that no other family suffers".

Their statement said: "The events of Vale of Leven started in late 2007. They are a shame on the conscience of the Scottish NHS. We believe in the NHS but our families' faith has been shaken to its very core. As a group we will not rest until the campaign for justice for our loved ones is satisfied.

"We are sincere in our belief that if we can prevent something like this from ever happening again then that at least will be a fitting tribute to the memories of the loved ones that we lost."

Ms Robison accepted that the "NHS failed in its duty of care for all of these patients and their families".

She added: "As the Cabinet Secretary for Health, that is a matter of deep regret for me, this Government and indeed the whole of the health service.

"That is why we will accept all 75 recommendations and go further where we can."

The Scottish Government will set up an implementation group to ensure that the recommendations are all implemented, with the families of those who died to be represented on it.

The Health Secretary also said she would be writing to all health boards in Scotland asking them to review their services in the wake of the report.

She said: "While NHS Scotland has moved on significantly in the intervening period, Lord MacLean's report gives us the further insight to ensure that the NHS does not fail patients and families as it did at the Vale of Leven.

"This report indicates a clear picture of the failings in the system that led to the C.diff outbreak. Its findings outline the lack of investment in the hospital, which was simply no longer fit for its purpose of providing modern health care. There was a lack of managerial oversight and a fundamental breakdown in the links between what was happening at ward level and those in positions of authority at the board.

"Added to this there had been long standing uncertainty over the future of NHS Argyll and Clyde. A merger with NHS Greater Glasgow was announced in 2005 but not effectively implemented until after the outbreak. This allowed bad practice and lack of managerial control at the Vale of Leven.

"At a national level there was no effective inspection regime at the time to pick up these failings and their impact on patient care. We now have an effective inspection routine through the Healthcare Environment Inspectorate that completes unannounced, comprehensive inspections and demands urgent actions."

Ms Robison said the report had found "clear failings across all levels in the system - including nursing and medicine through to management".

While she said C.diff had now been reduced to a record low level in hospitals, she added: "Of course we can do more, and we will use the recommendations to improve systems further - such as creating local infection taskforces and working to give Healthcare Environment Inspectorate the power to close wards.

"We must continue to act decisively and drive long term improvements based on Lord MacLean's recommendations. That is exactly what we will do, together with NHS Scotland and the families affected by this outbreak."

Robert Calderwood, the chief executive of NHS Greater Glasgow and Clyde, said: "Re-iterating my personal apology I hope the relatives can take some comfort that the lessons learned from this outbreak have resulted in significant improvements in clinical practice, for instance in more prudent prescribing of antibiotics.

"These major improvements introduced since the tragic events of six years ago have made the Vale and all of our hospitals in Greater Glasgow and Clyde safer for patients than they have ever been."

Jackie Baillie, the Labour MSP for Dumbarton, said: ''Today is a day of mixed emotions for the families of those who lost their lives between 2007 and 2008. They were vindicated in their call for a public inquiry as the report identified significant failings at every level of the health service and government.

''The C.diff outbreak at the Vale of Leven Hospital was the worst in the UK due to the high mortality rate.

''The families deserve nothing less than a full apology from the hospital management, NHS Greater Glasgow and Clyde and the Scottish Government for the mistakes which compromised patient care.

"What happened at the Vale of Leven should never be repeated anywhere in Scotland so it is vital we learn lessons and implement MacLean's recommendations in full.''

Scottish Conservative health spokesman Jackson Carlaw MSP said the report would be "extremely difficult reading" for those who lost loved ones.

He said: "Failing after failing is set out here, and there are very tricky questions for both the health board and the Scottish Government."

Mr Carlaw said that as Scotland's new First Minister Nicola Sturgeon was health secretary from May 2007 she would "have to explain why the infection control and inspection regimes were so inadequate, and why the Scottish Government wasn't paying attention to lessons being learned south of the border".

He added: "Many of the recommendations set out will already have been acted upon, and I'm sure NHS staff across Scotland are absolutely committed to an outbreak like this never being repeated.

"But now would be a good time to redouble our efforts on infection control, especially with a harsh winter coming down the tracks. Patients and their families expect and deserve nothing less."

SNP MSP for the West of Scotland Stuart McMillan said the report provided "a detailed analysis of the individual and systemic failures in care in NHS Greater Glasgow and Clyde that contributed to the C.diff outbreak in the Vale of Leven Hospital".

He added: "For the families that grieve the loss of their loved ones, and for the patients who were affected by the outbreak, I hope that this report can provide them with the answers they have sought.

"Time and again I've heard members of the families whose relatives died during the outbreak say that their aim is that no-one would again have to endure what they have endured.

"I welcome that the Scottish Government has accepted all of the recommendations made by Lord MacLean today. I am optimistic that the implementation of these recommendations - along with the substantial improvements to patient safety in the last six years - will mean that the tragic events at the Vale of Leven can never be repeated."