A PUBLIC inquiry into a catastrophic infection outbreak that claimed the lives of 34 people in a hospital has revealed shocking failures at every level, from basic nursing to the Scottish Government.
After a seven-year wait for answers, the families who lost relatives as a result of the Clostridium difficile bug spread at the Vale of Leven Hospital, Dunbartonshire, have heard they were the victims of a catalogue of appalling problems.
The report stated:
l Standards of nursing on the wards had lapsed.
l Medical staff were too junior.
l Managers did not know enough about what was going on.
l And the Scottish Government had failed to learn lessons from similar outbreaks elsewhere.
The report, published yesterday, said C. diff was a factor in the death of 34 patients treated in the hospital in Alexandria, which is in the NHS Greater Glasgow and Clyde health board area, between January 2007 and December 2008. In all, 131 patients tested positive for the bug in the first 18 months.
C. diff is a type of bacterial infection that can affect the digestive system. The report says there was little to suggest nurses were aware of the seriousness of C. diff, which can cause "explosive" diarrhoea and fatal complications in patients who are already unwell. Some relatives of those who fell ill were told it was a "wee bug".
Lord MacLean, chairman of the inquiry, said: "These figures are particularly damning when considered in the context of the Vale Of Leven Hospital, a hospital with around 136 beds in 2008."
The report, which has been delayed five times in part because Lord MacLean contracted an infection after a routine operation, paints a grim picture of the hospital at the time of the infections.
A number of services had already been cut and the future of key departments was uncertain. The inquiry found this had affected morale, recruitment of staff and the maintenance of the buildings - gaps in floor joints were being covered with duck tape.
According to the report, the clinician in charge of infection control for the Vale, Dr Elizabeth Biggs, was unhappy with her job, lacked support and her attitude to her role at the hospital was "wholly inappropriate and professionally unacceptable".
Lord MacLean and his inquiry team examined patient records as part of their research - something previous investigations into the scandal had not done. He said: "The unacceptable levels of care discovered were not the levels of care I would have expected to find in any hospital in Scotland."
He has made 75 recommendations and Shona Robison, the new Scottish Health Secretary, has promised to ensure they are all implemented. This involves health boards reporting how far they have got in making any necessary improvements and a change in the law to give the Healthcare Environment Inspectorate, the hospital inspection body, the power to close wards to new admissions.
She said: "This was a systemic failure at all levels, at the ward, at the board. It was a hospital out of sight, out of mind."
Patrick Maguire, the lawyer from Thompsons Solicitors representing the affected families, read a statement on their behalf. It said: "There are no words we can say to you today that will accurately convey the anger, hurt and grief we have felt for the past seven years over the suffering our loved ones endured as they succumbed to this terrible outbreak." They described events at the Vale as "a shame on the conscience of the Scottish NHS".
Negotiations are continuing about potential compensation. It is understood the total sum on the table is just over £1million. The cost of the inquiry is in excess of £10m.
Andrew Robertson, chairman of NHSGGC, apologised unreservedly to the patients and families affected. He said: "I can give the firmest of assurances that, as a result of the lessons learned, this could not happen again."
This year one patient has been diagnosed with C. diff at Vale of Leven Hospital.
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