THE past 12 months could well be described as NHS Greater Glasgow and Clyde’s annus horribilus.
The troubled health board will be back in the spotlight again today as Health Protection Scotland publishes figures detailing the infection rates among children in its cancer wards since 2016.
It comes days after the organisation was plunged into special measures and Scotland’s most famous bacteriologist, Professor Hugh Pennington, said he was “astonished” that the health board had not faced criminal charges over a catalogue of serious of infection control breaches detailed in a leaked report by the UK’s Health and Safety Executive (HSE).
Dated November 23 2018, it was issued to the health board just weeks before two cancer patients - a 10-year-old boy and a woman aged 73 - contracted infections caused by Cryptococcus, a fungus linked to pigeon droppings, during treatment at the Queen Elizabeth Hospital (QEUH). Their deaths are being investigated by the Crown Office.
READ MORE: Could we please end the hysteria about the NHS?
The HSE report tells of staff removing protective clothing while still inside patients’ rooms instead of using the decontamination zone; face masks not properly fitted; staff not immunised for tuberculosis (TB) working in high-risk infection areas; and a particularly damning instance of a nurse who had been given just one hour of on-the-job training before treating a patient with viral haemorrhagic fever, caused by highly contagious deadly viruses including Ebola.
Prof Pennington said the consequences of failing to follow procedure in these cases “could be disastrous”.
He said: “Cases of viral haemorrhagic fevers are very rare of course, but they do happen and the rules are there for good, sound reasons.
“Failure to follow them could result in infection being passed from patient to staff and then to the greater community.”
Alarm over the Cryptococcus cases in January was the moment when questions over the safety of the design, maintenance and infection control processes at the QEUH-RHC ‘superhospital’ campus came into sharp focus.
Confidence has never really be restored but the root of the problem remains to be found, with an independent review still to report its findings and a public inquiry commissioned.
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However, it is clear there were issues even before the £842 million facility opened in 2015.
A report in February by Health Protection Scotland revealed that the contractor responsible for building the complex was forced to sanitise the entire system before handing it over to the health board after sampling detected “hygiene issues with the water supply” and signs of unusually high microbial contamination.
Despite this, dozens of children treated in paediatric cancer wards 2A and 2B of the RHC are known to have contracted bloodstream infections traced to sinks, showers and drains.
A whistleblower claimed at the weekend that there were 10 infection cases in 2016, on top of the 26 already identified for 2017 and 23 between January and September 2018 - when the unit was eventually closed for remedial works.
Among the 2017 cases was 10-year-old leukaemia patient Milly Main, who was in remission when she suffered a fatal toxic shock after the catheter used to administer medication became contaminated with the bacteria Stenotrophomonas.
Police have also investigated the death weeks earlier in the same unit of three-year-old Mason Djemat, who was being treated for a rare genetic disorder and was ready to go home when he suddenly deteriorated and died.
READ MORE: Secrecy and defensiveness can only backfire on NHS
Infection problems surfaced again in ward 6A of the QEUH , where child cancer patients have been treated since last September.
A cluster of unusual infections forced NHS bosses to close the ward to new admissions in August, but a mother who spoke out anonymously at the weekend said her son had fallen critically ill with an infection in September and that his line tested positive for five separate bugs.
Cancer patients are especially prone to developing infections because chemotherapy weakens the immune system, so the key issue is whether infection rates at the superhospital are abnormal enough to suggest something unsafe.
“Many parents feel they are not being told the full truth,” said Monica Lennon, Scottish Labour’s health spokeswoman.
TIMELINE
April 27 2015: Queen Elizabeth University Hospital opens on the site of the former Southern General.
June 10 2015: Royal Hospital for Children opens. It features a cinema, indoor and outdoor play areas, and a roof garden.
September 18 2018: Children are transferred from wards 2A, 2B and the adjoining Bone Marrow Transplant unit into the QEUH adult hospital following a string of bloodstream infections traced to taps and shower heads. NHS GGC says that drains are experiencing a rapid build up of biofilm (bacteria, fungi and other microorganisms) despite deep-cleaning.
November 23 2018: HSE issues critical report to NHS GGC over infection control measures.
December 2018: NHS GGC confirms the children’s wards will remain closed while a £1.25 million ventilation upgrade is completed.
January 18 2019: The deaths of two cancer patients, aged 10 and 73, who had been treated at the QEUH are confirmed. Both had contracted an infection caused by the fungus Cryptococcus, believed to have entered the hospital’s ventilation system from pigeon droppings. The Crown Office is investigating both deaths.
January 23 2019: Health Secretary Jeane Freeman announces an independent review into the design, construction and maintenance of the QEUH and RHC, to determine whether this has increased infection risk.
February 22 2019: A Health Protection Scotland report reveals there were concerns over unusual levels of water contamination and bacteria at the hospital complex before it opened.
September 17 2019: Ms Freeman announces a joint public inquiry into the construction of both the QEUH/RHC complex and the new Royal Hospital for Children in Edinburgh after design faults with ventilation at the Edinburgh hospital delay its opening until 2020. Both were built by private contractor, Brookfield Multiplex.
November 14 2019: A whistleblower reveals that a clinician-led review at NHS GGC had identified 26 cases of infection in wards 2A/2B in 2017potentially linked to the water supply, including the death of 10-year-old Milly Main on August 31 2017. The report had been shared internally, but not with parents or the Scottish Government, prompting accusations of a cover up. The mother of Mason Djemat, three, says she also wants answers over the sudden death of her son in the same unit on August 9 2017.
November 22 2019: NHS GGC is escalated to Level 4 status.
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