£842m hospital report says failures ‘did not cause avoidable deaths’

Jeane Freeman and the QE2 Hospital, which serves Glasgow and West Dunbartonshire.

By Democrat reporter

BBC Scotland is reporting that a new report has said there were a “series of problems” with the design and build of an £842 million hospital campus – but no clear evidence to link those failures to any “avoidable deaths”.

The Queen Elizabeth University Hospital opened in 2015, but fears were raised after deaths were linked to infections.

An independent review concluded that some patients had been “exposed to risk that could have been lower”.

However, it found no “sound” evidence that there had been “avoidable” deaths.

And the review team said the hospital campus now “has in place the modern safety features and systems that we would expect”.

A public inquiry is also to be held into issues at the Glasgow hospital and the long-delayed Royal Hospital for Children and Young People in Edinburgh, which has the same building contractor.

Glasgow’s £842m Queen Elizabeth University Hospital has had issues with rare microbiological contaminants since opening, linked to issues with water quality and ventilation systems.

Two people who died at the hospital were found to have contracted Cryptococcus fungal infection which can be linked to pigeon droppings.

The 10-year-old boy and 73-year-old woman died at the hospital campus, which is also home to the Royal Hospital for Children (RHC), in January 2019.

A third death, involving a 63-year-old patient who contracted the fungal infection Mucor, is also being investigated.

Ministers commissioned an independent review to establish whether the design, construction or maintenance of the hospital was having an “adverse impact on the risk” of infection.

Dr Brian Montgomery and Dr Andrew Fraser wrote in their report that there had been a “series of problems” with the project.

They said: “Undoubtedly and with hindsight the health board, groups within it and the design and build contractor could have reached different decisions and produced results that would have reduced infection risk.”

They said some patients had been “exposed to risk that could have been lower if the correct design, build and commissioning had taken place”, and that certain elements of the design and build of the facility “posed challenges” for infection prevention and control.

However, they concluded that they had “not established a sound evidential basis for asserting that avoidable deaths have resulted from failures in the design, build, commissioning or maintenance” of the campus.

pigeon feeder.jpg 2

Pigeons, which caused serious problems at the hospital.

The report said that while pigeon droppings were found near an air inlet in the hospital, the patients who were affected by Cryptococcus did not spend much time in areas supplied by that part of the system.

The authors said the presence of pigeons within the hospital was “not sufficient to establish a strong association or causative link” with the infections, and that the idea they were caused by “contaminated air” was “not a sound theory on its own”.

The report concluded that patients, staff and visitors can have confidence that the combined hospitals now have “modern safety features and systems” and offer “a setting for high quality healthcare”.

However Health Secretary Jeane Freeman said patients and families would be “understandably concerned and distressed by some of the findings” of the review.

She said it was an important step in delivering answers to “the many questions they are entitled to ask”.

“The report provides a wealth of information for the forthcoming public inquiry into the construction of the QEUH and the Royal Hospital for Children and Young People in Edinburgh,” she said.

“I would like to thank the review team for their diligence in carrying out this report and the hospital staff for their focus on providing high quality care throughout this challenging time.”

‘Utterly damning’

Ms Freeman told MSPs that the inquiry, which will be led by Lord Brodie, was “on track to be formally launched in early August”.

Scottish Conservative health spokesman Miles Briggs said the “explosive report” was an “utterly damning verdict on the SNP government which planned, commissioned and built this hospital”.

Anas Sarwar MSP, Lord Brodie and Miles Briggs MSP.

He added: “It very clearly concludes that patients young and old with cancer – the same group from which people died – were placed at increased risk because of the building and design of the hospital.

“Patients and families want answers and the independent public inquiry which is to now proceed must be able to undertake that work and have full transparency and access to provide answers.”

Labour MSP Anas Sarwar said there was “still a lot of work to do to uncover the full truth” about “the scale of the scandal and the catastrophic errors which took place”.

Drs Montgomery and Fraser said they had focused their review on “potentially vulnerable patients and their families and the clinical teams, management and facilities staff who support their care”.

They said: “We judge that the hospital was not built, finished and handed over in a manner that took full account of their specific needs.

“Certain aspects of the design, build, commissioning and maintenance of the QEUH have posed challenges in creating the optimal conditions for infection prevention and control, and have increased the risk of healthcare associated infection.”

They said the design of the hospital “did not effectively reconcile conflicting aims of energy efficiency and meeting guidance standards for air quality”, and said there had been “difficulties” with the air and water systems due to “ambiguity” about guidance.

‘Undermined by problems’

They said the project “would have benefited from greater external expertise” in decision-making at key points, and that the level of independent scrutiny of the commissioning, design and build phases was “not sufficient”.

And the doctors said the effectiveness of infection prevention and control was “undermined by problems within the leadership team” and internal relations within the health board’s staff.

West Dunbartonshire health board representative Cllr Jonathan McColl, Chief Executive Jane Grant and Chairperson John Brown.

The report said the “series of problems” with the project had had a “multitude” of knock-on effects, including:

  • Eroding public confidence in the hospital’s ability to protect them from healthcare hazards
  • Disrupting treatment for certain groups of patients and creating concern for their families
  • Creating “additional workload” for infection prevention and control teams
  • Diverting resources and attention away from running the “large and complex facility”
  • Undermining the reputation of the hospital.

The authors made a total of 63 recommendations for NHS Greater Glasgow and Clyde, the hospital and its staff and the Scottish government, saying that “lessons can be learned that will enhance confidence in future major projects”.

And they said research should be carried out about air and water quality in clinical environments and the significance of “rare microorganisms” to inform planning in future.

* Cllr McColl is the person who once said he had better things to do than go to a Health Board meeting, such as catch up with his office mail – Editor

Meanwhile, this statement was issued at 5.30pm today (Monday) by the Health Board: Questions around the safety of the hospitals on the QEUH campus have persisted for some time, causing distress to a number of families and a great degree of public concern. We are very sorry that this situation has arisen and for the anxiety this caused.
The independent review by Dr Fraser and Dr Montgomery provides a comprehensive assessment of issues that arose with the QEUH and the RHC in relation to their design, build, commissioning and maintenance and we welcome the publication of their report.  
Today’s report highlights a number of shortcomings by the Board, its contractors and its advisers at various stages of the design, build, commissioning and maintenance of the QEUH and RHC.  It also recognises that since the hospitals opened, we have taken remedial action to resolve a wide range of issues, some of which are now subject to legal action against the contractors and the advisers.
The report also concludes that there is no sound evidential basis for avoidable deaths having resulted from failures identified with the design, build and maintenance of the QEUH campus, including the water system and that the link between air changes and infection risk has not been established.  Furthermore, it finds no sound evidence linking the instances of Cryptococcus infection to the presence of pigeons on the campus. 

[The report does state, however: Two people who died at the hospital were found to have contracted Cryptococcus fungal infection which can be linked to pigeon droppings.] Editor
The report finds that our hospitals are delivering high quality healthcare, supported by modern safety systems and features.  It recognises the significant efforts of our infection control teams, along with clinical colleagues, to ensure patient safety and to reduce infection rates in our hospitals.
We hope that today’s report provides some comfort to families who have had unanswered questions about factors contributing to the death of their loved one and helps restore public confidence in the safety of the hospitals.  We would like to apologise again to those families that these issues have arisen and for the time taken to resolve them.
Welcoming the report, Jane Grant, Chief Executive, said:  “This has been a very difficult period for our patients, their families and our staff for which we apologise.
“The findings highlight several areas of learning for NHSGGC [the Health Board].  We remain fully committed to applying the learning from this experience.  We also remain focused on remedying any ongoing consequences of decisions and actions taken when designing, building and commissioning of the hospitals and in their maintenance.
“The report highlights issues concerning previous ways of working in one area of the Board with regard to Infection Prevention and Control.  We recognise that there are still issues to be addressed concerning the organisation’s culture.
“We would like to thank Professor Marion Bain and Professor Angela Wallace for their work on behalf of the Scottish Government to support the team to develop a more supportive and inclusive culture in this area.
“Whistle-blowing is an important factor in better understanding issues and promoting a culture of openness where staff feel confident to raise concerns.  We are committed to supporting whistle-blowers within our organisation and thank those who came forward with their concerns about the hospitals.”
Professor John Brown CBE, chairman, added: “We hope that this report, and the lessons from it, can enable the Health Board to move forward, to restore public confidence in the QEUH and the RHC and to help re-build the reputation of these hospitals to one based on the high quality, person centred care being provided by our hard working and committed staff rather than on the problems we experienced with the design and construction of the buildings.”


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