'Human error' in ventilation flaws at Edinburgh Sick Kids

The Royal Hospital for Children and Young People (RHCYP) was ready to welcome its first patients in July 2019 when a last-minute inspection discovered safety concerns.

It eventually opened in March 2021 following at least £28 million of repairs and additional costs, exacerbated by the pandemic.

The cause of the fiasco is being examined as part of the Scottish Hospitals Inquiry, which is also probing whether design flaws at Glasgow's Queen Elizabeth University Hospital (QEUH) and its adjacent children's hospital put patients at an increased risk of deadly infections.

READ MORE: Inside Edinburgh's new Sick Kids' as hospital finally opens

In its closing submission in relation to the Edinburgh project, the counsel for the inquiry told chair Lord Brodie that there had been a "lack of clarity" at the outset as to whether the specification for the building's ventilation system fully complied with guidance known an SHTM 03-01 which sets out best practice for a safe and effective hospital.

It added that the "genesis of the problem was an error in a technical spreadsheet called an Environmental Matrix", which dated back to 2012.

This ultimately resulted in a "disconnect between what [NHS Lothian] wanted the ventilation system to achieve and what the successful tenderer believed the ventilation system required to achieve".

Lord Brodie is chairing the inquiry (Image: PA)

A deal signed in 2015 saw private consortium, IHSL - which includes QEUH developer Brookfield Multiplex - awarded the contract to design, build, finance and maintain the hospital over 25 years as part of a Non-Profit Distributing (NPD) system, the Scottish Government's version of PFI. The cost of the project now exceeds £430m.

However, by 2018 NHS Lothian was on the verge of mounting legal action against IHSL - also known as Project Co - to “force” it to design the ventilation “in accordance with their contractual obligations”.

READ MORE: NHS director speaks of 'uncomfortable compromise' in Edinburgh hospital build

This was shelved with the issue seemingly resolved, only for shortcomings to be discovered the following year.

The counsel's closing submission said that the "initial versions" of the Environmental Matrix had "contained appropriate environmental parameters, including air changes rates, for critical care rooms".

However, engineers developing the matrix subsequently decided to insert a "room function reference sheet" which seeded errors with the ventilation.

Inside the new sick kids' hospital in Edinburgh (Image: PA)

Counsel states: "In the preparation of this sheet, room functions for various areas in the hospital were determined by engineers without consulting with clinicians or infection prevention and control specialists.

"For certain critical care areas, air change rates for a standard ward were inserted when the values for a high dependency unit should have been inserted.

"It is unlikely this mistake would have happened if there had been direct discussions between the engineers producing the Environmental Matrix and the clinicians responsible for using the specific rooms."

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The submission goes on to say that these errors in critical care "were not detected by [NHS Lothian] or its technical advisors before the contract was signed with the successful tenderer", adding: "This was a mistake. The Inquiry has seen no evidence indicating any deliberate concealment or failure to disclose wrongdoing."

However, the inquiry has also been told that further confusion arose because NHS Lothian insisted that it did not intend for the matrix to be used as a "definitive statement" of its design brief, but that this was not made clear to those bidding for the contract.

Towards the end of the procurement phase, however, engineers acting for the health board identified gaps between the matrix and SHTM 03-01 guidance.

The construction and maintenance of the QEUH in Glasgow and its adjacent children's hospital are also being probed as part of the Scottish Hospitals Inquiry (Image: PA)

The counsel submission states that these issues "were the subject of discussion, prior to financial close, between [NHS Lothian] and the IHSL consortium" and "included concerns that room pressure parameters specified in the matrix were contrary to the guidance and gave rise to a risk of spreading infections such as MRSA and norovirus".

However, with the health board "under pressure to sign the contract" no corrections were made and and data in the matrix was classified as "reviewable".

The inquiry is due to resume on Monday with evidence from clinical staff in relation to the Glasgow sites.

Core participants for the Edinburgh project - including NHS Lothian - are expected to respond to the counsel's submission later this month.