Infections which led to the death of two children at the Royal Hospital for Children in Glasgow were not escalated quick enough or 'acted upon', a damning report has concluded.
Health Secretary Jeane Freeman said NHS Greater Glasgow and Clyde will remain in Level 4 'special measures' after significant failings in infection prevention and control, governance and risk management at the Queen Elizabeth University Hospital campus were highlighted by two government reports.
The independent Case Note Review, led by Professor Mike Stevens, investigated 118 episodes of a particular type of serious infection, caused by Gram-negative environmental (GNE) bacteria, from 2015 to 2019. Patients were aged between three months to 18 years and were all receiving treatment for blood disease, cancer or related conditions.
It found that a third of these infections were ‘most likely’ to have been linked to the hospital environment, and that the deaths of two of the 22 children who had died were, at least in part, the result of their infection.
Both children had other serious medical problems and the review concluded that "even without the infection", their survival would still have been uncertain.
While the two children have not been identified, Kimberley Darroch believes they include her daughter Milly Main, who died after picking up an infection while recovering from a stem cell transplant to treat her cancer.
A third of infection episodes were rated as having a severe or critical impact on patients.
The report was critical that despite more than five years of experience in investigating outbreaks of GNE bacteraemia and concerns about the hospital environment, NHS GGC had not established an electronic database of microbiological typing results and therefore 'had no ability' to link infections.
The infection episodes resulted in longer hospital stays for patients and the need for additional treatment, as well as delays in planned treatment in some cases.
While noting NHS Greater Glasgow & Clyde (NHS GGC) had made some improvements, the Expert Panel made 43 recommendations including improvements in environmental surveillance and how water sampling and testing are used to better inform investigations of possible links between clinical infections and water or environment sources.
Individual reports will be prepared for the families of those patients affected by the infections at the QEUH.
In addition, the Oversight Board chaired by former Chief Nursing Officer Professor Fiona McQueen has published its final report on infection prevention and control, clinical governance and communication with patients and families.
It acknowledged that NHS GGC has taken strong remedial action to find and address water contamination issues, however the health board's overall response was deemed 'short-term and reactive".
There were significant failings in governance, including infection numbers and building issues not being sufficiently escalated or acted upon.
It found substantial evidence of frontline staff taking a compassionate approach to communicating with families but that this had been inconsistently applied at a Health Board level.
READ MORE: Health board set for legal challenge over ward infection risk
In response, Jane Grant, Chief Executive of NHS Greater Glasgow and Clyde, said she was "truly sorry" for the distress caused to the parents of children affected.
She said: "Whilst we have taken robust and focused action to respond to issues, and at all times have made the best judgements we could, we accept that there are times when we should have done things differently."
In total, £6million was spent on addressing water supply issues with a further £8million invested in Wards 2A and B, including a significant upgrade of the ventilation system.
The health board say this will deliver one of the safest clinical environments in the UK.
Health Secretary Jeane Freeman said: “These findings, which will inform the ongoing Public Inquiry, do not fault the quality of care provided by frontline NHS GGC staff, but they do highlight serious failings at the Health Board level. I agree with the Oversight Board’s conclusion that NHS GGC should remain at Stage 4.
READ MORE: QEUH: Freeman must stop whistleblowers being victimised
“Efforts have been made to improve and adopt the culture of transparency, openness and clinical leadership I expect. However, we will continue to work closely with the Board to ensure these are demonstrably embedded – to provide the assurance patients and their families deserve, and also so that these lessons can be considered more widely across NHS Scotland.
“I want to again extend my deepest sympathies to the families of patients who died, and to everyone who has been affected as a result of the issues raised, on top of the significant distress, anxiety and disruption they will already have faced with loved ones in hospital.
“Ensuring that affected families are supported and fully engaged is of paramount importance, and in addition to the individual engagement the Case Note Review team will undertake with each family, it is very welcome that the Public Inquiry has appointed a Family Liaison Officer who will play an important role in ensuring full engagement and communication with families as the Inquiry progresses."
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