An inquiry into an outbreak of Clostridium difficile infection at a Scottish hospital which led to the deaths of 34 patients has identified a number of serious failures, both on a personal and systemic level.
The patients died after contracting C. difficile in the two years between January 2007 and December 2008 at the Vale of Leven Hospital.
The Vale of Leven Inquiry found that a total of 143 patients tested positive for C. difficile in the period.
Lord MacLean, who chaired the inquiry, said more people are likely to have died from the infection, but not all of their medical records were available.
The inquiry report, published yesterday, identified a number of failings:
- Governance and management failures within NHS Greater Glasgow and Clyde which created an environment in which patient care was compromised and infection prevention and control was inadequate
- Inadequate attention given by NHS Greater Glasgow and Clyde and the Scottish Government agencies to reports about other CDI outbreaks in the UK which identified failures similar to many of those at Vale of Leven Hospital
- Significant deficiencies in infection prevention and control practices and systems which had a profound impact on the care provided to patients in the hospital
- Deficiencies in nursing care and medical care which seriously compromised the care of patients
- Uncertainty over the Hospital’s future which had damaging effects on recruitment, staff morale and the hospital environment
- Lack of strong management which contributed to a culture unsuited to a caring and compassionate hospital environment
“Our top priority is that lessons are learned so that what happened at the Vale of Leven can never be allowed to happen again”
Following the release of the inquiry’s report, NHS Greater Glasgow and Clyde chair Andrew Robertson apologised “fully and unreservedly” on behalf of the board and staff to patients and their families
The board’s chief executive Robert Calderwood also offered his apology to those affected, as did Scottish health secretary Shona Robison.
Accepting all recommendations made in the report, she said: “Our NHS failed in its duty of care for all of these patients and their families. As the cabinet secretary for health, that is a matter of deep regret for me, this government and indeed the whole of the health service.
“That is why we will accept all 75 recommendations and go further where we can. As well as creating our implementation group, I am today writing to all health boards to ensure they review their services against the report and respond to the government within eight weeks,” she said.
“This report indicates a clear picture of the failings in the system that led to the c.diff outbreak,” said Ms Robertson.
“Its findings outline the lack of investment in the hospital, which was simply no longer fit for its purpose of providing modern healthcare. There was a lack of managerial oversight and a fundamental breakdown in the links between what was happening at ward level and those in positions of authority at the board.
“Added to this there had been long standing uncertainty over the future of NHS Argyll and Clyde. A merger with NHS Greater Glasgow was announced in 2005 but not effectively implemented until after the outbreak. This allowed bad practice and lack of managerial control at the Vale of Leven,” she added.
“At a national level there was no effective inspection regime at the time to pick up these failings and their impact on patient care,” she said. “We now have an effective inspection routine through the Healthcare Environment Inspectorate that completes unannounced, comprehensive inspections and demands urgent actions.
“The report highlights those who either abdicated their responsibilities or failed to carry them out effectively. There is no place for this conduct in our NHS, which fell below even the minimum standards we expect. It is for the health board as the employer to consider the implications and we would expect them to consider the report’s findings on this aspect urgently,” Ms Robertson said.
“The report found clear failings across all levels in the system, including nursing and medicine through to management.
“We have already announced that Scotland’s interim chief nursing officer will be working closely with board nurse directors to develop local quality assurance programmes to empower their senior charge nurses to fulfil their role as guardians of quality care.
“I want to go even further and will be asking that information from these quality assurance programmes is publicly available and easily accessible to patients and the public. We will also roll out national standards for nursing documentation and care planning, which will be monitored as part of the quality assurance programme.
“Of course we can do more, and we will use the recommendations to improve systems further, such as creating local infection taskforces and working to give Healthcare Environment Inspectorate the power to close wards.
“Our top priority is that lessons are learned so that what happened at the Vale of Leven can never be allowed to happen again.”
The Scottish Government said it will carefully consider the full report, working with families, stakeholders and across the Parliament.
A full response to the report will be published in spring 2015, it said.
Royal College of Nursing Scotland director Theresa Fyffe said the outbreak had “devastating consequences”, and lessons must be learned to make sure an incident such as this never happens again.
She added that the report “makes difficult reading for nurses everywhere”, as failures were found in a number of different areas.
- A full copy of the Inquiry report including an executive summary is available on the inquiry website