A RISK assessment carried out in the same week that patients were first admitted to Glasgow's flagship hospital warned that the water supply was not safe, leaked reports reveal.

Labour MSP Anas Sarwar said a catalogue of infection fears raised by staff and experts were ignored in the months leading up to the death of leukaemia patient Milly Main in August 2017, adding that there would be a criminal investigation if the scandal had unfolded in the private sector.

HeraldScotland: Lord BrodieLord Brodie

It comes as Health Secretary Jeane Freeman announced that Lord Brodie will chair the public inquiry into the construction of the £842 million Queen Elizabeth University Hospital and its adjacent Royal Hospital for Children in Glasgow, and the delayed Royal Hospital for Children and Young People in Edinburgh.

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Documents passed to Mr Sarwar show that a water risk assessment dated April 29 2015 found "significant communication issues" between the legionella management team and a "high-risk" of the potentially deadly bacteria developing in five of the eight water heaters that supplied the hospital's hot water.

Where there is a high risk of legionella, there is also a high risk of other water-borne bugs.

The same report, carried out by Lanarkshire-based independent contractor DMA Canyon Ltd, warned of sludge and slime was able to build up in some sections of pipework, potentially leading to contaminants being released into the water supply.

Despite warnings from the contractor, the QEUH began admitting patients in April and was fully occupied by June 2015 - when the RHC also opened its doors for the first time.

There were 50 cases of infections linked to sink, drains and showers in the paediatric cancer wards 2A and 2B between 2015 and the unit's closure in September 2018.

Among those believed to have fallen victim is 10-year-old Milly Main, who suffered toxic shock after her Hickman line - used to administer drugs intravenously - became contaminated with the bacteria Stenotrophomonas, typically found in water, plants or soil.

A further 15 cases have also been reported so far this year in ward 6A of the adult hospital - where child cancer patients are now being treated - although the source of the infections is unconfirmed.

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Cancer patients are more likely than other patients to contract infections because of the way their immune systems are weakened by chemotherapy.

Mr Sarwar said he had been passed information indicating that hospital staff had begun raising concerns about line infections among patients in cancer ward 2A by March 2017, and that infection-control doctors alerted management to issues involving Stenotrophomonas in particular in August 2017.

He said these had been escalated to Health Protection Scotland and the Scottish Government.

A follow-up report by CMA Canyon Ltd in report carried out September and October 2017 said there had been "no significant water system alterations", and found "very dirty water" when a number of water heaters.

It said: "DMA were advised during the initial occupation phase that the filter system was bypassed due to issues with the pumps and filter set, and this may have introduced contamination, debris (and potentially bacteria) into the system.

"As the tanks have not been cleaned since this time, any material or contamination could potentially have been flushed into the system and have colonised parts of the system."

A final report in January 2018 identified "significant gaps" in infection controls.

The report added: "We would advise corrective actions are taken as a matter of immediate urgency.

"We would describe the legionella management on site as being high risk until remedial actions highlighted with the risk assessment and within this gap analysis are implemented."

The report also said the estates manager responsible for the water supply had "little knowledge" of the systems and had not undergone any training in infection controls.

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The QEUH project was completed on time and on budget by Brookfield Multiplex - the same contractor responsible for building the RHCYP in Edinburgh - but Mr Sarwar suggested that there had been a rush to open the facility before it was ready.

He said: "A report done the week the hospital was opened revealed that the water supply was not safe and there was a high risk of infections. Yet the hospital still opened.

"Months before Milly died infection control doctors raised concerns about line infections in the children's cancer ward.

"Three weeks before Milly died infection control doctors alerted management of further concerns about infections, escalated this to Health Protection Scotland and the Scottish Government, and requested testing of the water.

"A month after Milly's death an assessment of the water supply again found the water was not safe and that there was a high risk of infections."

He added: "At each of these stages the warnings were ignored and appropriate action was not taken. It led to the death of a child.

"If this happened in the private sector there wouldn't be a public inquiry, there would be a criminal investigation.

"The First Minister, Health Secretary and health board officials must detail who knew what and when."

The First Minister assured the Glasgow MSP the Scottish Government were determined to get the answers "that Milly's parents and the parents of any children who have been treated at the Queen Elizabeth want and deserve".

Ms Sturgeon said she had not seen the evidence from Mr Sarwar, and urged him to share it with the Scottish Government.

Health Secretary Jeane Freeman said the safety of patients will always be her "top priority" as she confirmed that she will meet with Lord Brodie before the end of the year to discuss the timescale for the public inquiry and the issues it will cover.

Ms Freeman added: "The safety of patients and their families will always be my top priority - they must have the right support and information to give them confidence that they are receiving the best care possible from our NHS.

"This inquiry and its recommendations will help us learn lessons from recent issues so they are not repeated in the future.

The public inquiry, announced in September, will be in addition to an existing independent review into the design, build, commissioning and maintenance of the QEUH and RHC.

The review was commissioned in January following the deaths of two cancer patients who had contracted an infection caused by a fungus linked to pigeon droppings while being treated at the QEUH. Both deaths are also being investigated by the Crown Office.

Problems have been identified with ventilation design at both the Glasgow superhospital and the RHCYP in Edinburgh, which was supposed to open in summer but is now undergoing remedial works. It is not expected to be fully operational until autumn 2020.

A spokeswoman for NHS Greater Glasgow and Clyde said: "The safety, wellbeing and confidence of our patients and our staff is, was and always will be our absolute priority.  We apologise to patients for the distress and anxiety caused and are focused on addressing their concerns. 

"We fully acknowledge that there have been issues at this site and senior managers sought to take robust action to address these issues when they became aware of them.

"We led, and asked for expert help, to investigate and resolve these issues and reports about these incidents are available to the public. 

"In response to ongoing issues, we commissioned a further comprehensive independent technical review in 2018 which we believe can help inform the Cabinet Secretary’s wider external independent review into design, construction and maintenance of the QEUH/RHC.

"The potential link between the water supply and cases of infection in 2018 has already been fully reported.  The Health Protection Scotland report highlights all the actions that were taken by the Board – together with an acknowledgement that patient safety is at the forefront of our considerations. 

"This has now resulted in a safe and effective water supply. 

"Responding to the points raised in turn: 

"2015 and 2017 water services reports: In 2018 we carried out a full investigation into the handling of the routine water risk assessment reports.  Key changes have been implemented and the water system is safe, wholesome and well maintained. We have a robust monitoring structure to keep it safe. 

"All the reports have been acted on and were shared with Health Protection Scotland and Health Facilities Scotland when the independent review of the water contamination issue in 2018 was carried out.

"Routine water sampling was carried out from the time the hospital opened.  Specific tests were also carried out at the request of infection control doctors when investigating possible infections.

"Our electronic records, available from April 2017, show that we tested 542 water samples from the Royal Hospital for Children water system until December that year. 

"None of the samples tested were positive for Stenotrophomonas. This includes 40 samples taken during the month of August - none of these were positive for Stenotrophomonas. This is the period that investigations were ongoing into two possible cases of linked Stenotrophomonas.

"March 2017: In March 2017 concerns raised by hospital staff about line infections were taken extremely seriously and an expert clinician group with surgeons and oncologists and other clinical experts was set up with the result that over the following months the rates reduced significantly.  We also involved international experts from Cincinnati to advise on the latest scientific evidence on how to protect our vulnerable patient population. 

"The result of this was that we currently have the lowest rates of gram positive infections in this group of patients in Scotland. We have some of the most vulnerable patients in the country as we provide a number of highly specialist national services and so these results are very encouraging. 

"August 2017 investigation into Stenotrophomonas: The investigations into two possible linked cases of Stenotrophomonas in August 2017 were carried out by an experienced infection control doctor and infection control nurse and the clinical team.  This was reported to Health Protection Scotland at the time.  In October 2017, this investigation was reported in public to the Board. 

"2018 report into limited knowledge of the water systems: This issue around understanding the risks in the water system was addressed when we trained staff to become specialists in managing domestic water systems. 

"This has now been completed and independently validated with our staff formally being appointed as authorised persons (AP water) in accordance with SHTM 04-01 Part B."