CULTURE PROBLEM IN HEALTH BOARD LED TO WHISTLEBLOWERS BEING IGNORED

 Health Secretary Jeane Freeman, the QE2 and Royal Children’s Hospital and Lord Brodie, who will preside at the public inquiry.

 By Bill Heaney

In an astonishing statement in the Scottish Parliament on Tuesday,  the Cabinet Secretary for Health and Sport, Jeane Freeman, thanked  whistle-blowers for “their courage and persistence in the face of the difficulties that were placed in their way as they attempted to report faults”  in the design, build, commissioning and maintenance of the Queen Elizabeth university hospital and the Royal hospital for children.

The £842 million “showpiece” hospital has been at the centre of controversy and criticism for two years over  patient deaths and whether faults in the design, build, commissioning and maintenance of the hospital were in any way to blame for them.

In other words, did these things, which included contaminated water and pigeon droppings inside the hospital, have an adverse impact on the risk of healthcare associated infection, and whether there is wider learning for NHS Scotland.

Ms Freeman told MSPs: “I have welcomed the report,  its important findings and recommendations, and the contribution that it will make to the [forthcoming] public inquiry. I will respond fully to its findings and recommendations in due course.

“In thanking Dr Fraser and Dr Montgomery [the report authors] for their considerable work, I record again my sincere thanks to the whistle-blowers for their courage and persistence in the face of the difficulties that were placed in their way.”

This statement raised not a few eyebrows given that there are outstanding issues involving Health Boards and whistle-blowers currently before the law and which are sub judice, which means they should not be matters of public debate or discussion until they have been disposed of by the courts.

Ms Freeman added: “I recognise that for some of the families who have been affected the report does not provide all the answers that they rightly ask for, but I hope that the report, the outcome of the independent case review that is under way, and our response to both will assure them of the extreme seriousness with which I take their concerns.

Anas Sarwar MSP told parliament: “I welcome that response from the cabinet secretary. It is a small step in the right direction although, sadly, it leaves many big unanswered questions.  As the health secretary said, the report is one of several pieces of work. It is crucial that any process takes with it the families who have been affected. That is not helped by there being clear inconsistencies.

On one hand, the co-authors say that the review was not about looking at individual cases, and that they therefore did not speak to families, but, on the other hand, the report makes judgments on individual cases.

“That is not acceptable. Its success or failure will depend on getting answers from [deceased patient] Milly Main’s parents and all the parents who have been affected. Will the cabinet secretary give a firm commitment that families will be at the heart of the next stages—namely, the clinical case review and the public inquiry?”

Jeane Freeman assured him that they would be. She replied: “I am very happy to give Mr Sarwar that assurance. As he probably knows, following my meeting with a number of the families involved, we undertook a number of actions, one of which was to place a very senior clinical member of my team in Queen Elizabeth university hospital as direct liaison between the board and the families, to ensure that when the families had questions on any matter, they were speedily given full answers. He continues to do that work.

“Families have been involved in the work of the oversight board and its design, and have assisted in developing how the independent case review will go forward. Individual families in specific cases that will be independently reviewed are aware of that, and have the option to be alongside the case review while it happens—or not, depending on how they want to engage. They will certainly be involved and will have the findings of the case review fully reported to them in person, and will have as many opportunities as they need to return with further questions.

“Finally, the remit of the public inquiry was considered by the families involved in order to ensure that it would achieve what they hoped that it would achieve. Members of Parliament were also given the opportunity to comment through their parties’ health spokespersons.

“The remit is now finalised. I will speak to Lord Brodie later this week. I hope, following that, to be able to update members on when the public inquiry will begin. Lord Brodie has been keen from the outset to understand how he can best engage with the families; I understand that he intends to appoint a family liaison officer to the inquiry, in order to ensure that that happens.”

Anas Sarwar persisted: “The authors of the review accept that their report was about the future, not the past. However, the past matters, especially to those who have lost a child, because there are indisputable facts.

“The Queen Elizabeth university hospital was built with design flaws. The independent water-quality report at the time of opening found that there was high risk of infection. That was not actioned at the time, and there were infections in children. Milly Main died from Stenotrophomonas infection; that is written on her death certificate.

Chairman John Brown and Chief Executive of the Health Board, Jane Grant.

There is a culture problem, and there was an attempt by the leadership of the health board to ridicule and silence whistle-blowers. Does the cabinet secretary accept that the public inquiry must look at those issues and provide answers? Will she publicly support Milly’s parents’ demands for a fatal accident inquiry, so that they can try and get justice and answers on their daughter’s death?”

Jeane Freeman agreed that the past matters. She said: “It is often unanswered questions about the past to which many families desperately require answers. I completely concur, and I believe that the public inquiry will work very hard to address that. It needs to look at the past in order to provide answers and the lessons that we need to learn for future infrastructure building in our national health service.

“The independent case review—with independent experts in their field looking case by case—is also looking at the past. I hope that all the families, who have been contacted, choose a way of engaging with the case review that best meets their needs. As I said, they have a range of reviews.

“I understand that Ms Darroch’s case—Milly’s case—has been reported to the procurator fiscal. Cases need to go through due process, in which—as I know Anas Sarwar understands—it would not be appropriate for me to intervene. We need to let that happen, we need to let the public inquiry begin, and we need to see how Milly’s mum feels as a consequence of the review of her daughter’s case. We will then see whether we need to take further steps.” 

Conservative MSP Miles Briggs, who had a very public dust up with FM Nicola Sturgeon the other, said: “I have two questions. First, on 28 January, the cabinet secretary told me that the 80 families who had been identified would have, at the very least, a face-to-face talk through with regard to their specific case. Has that happened?

“One of the points in yesterday’s report was that the impact and benefits of single rooms should be reviewed and that any future design around that should be considered. Will the Scottish Government now review single-room occupancy in hospitals?”

 

Jeane Freeman said the work of the independent case note review has been delayed— “as Miles Briggs might expect, it is taking longer because of Covid-19”.

She added: “The independent reviewers are working through different ways in which they can have that face-to-face talk through, the commitment to which remains. They have undertaken some of that, and it will take longer.

“It is now anticipated that the initial report will be available in the autumn. However, that may not be the complete report; it depends on how they can meet the commitment to the face-to-face talk through in circumstances in which we are still dealing with Covid-19.

Labour’s Monica Lennon, the Children’s Hospital and Tory Miles Briggs.

“In relation to single rooms, I note from an initial reading of the report—I am sure that I will read it again more than once—that the specific point that was picked up was in relation to the maintenance of, in particular, hand wash basins and the water supply in single rooms in which, inevitably, the water flow was not as great as in a four-bedded bay in which the water was used more often.

“There was a maintenance issue that was not picked up and addressed at the outset. That is part of what we need to consider as we progress, because we know that single rooms also play an important role in effective infection prevention and control, notwithstanding the points that the report makes in that regard.”

 

She added: “The national body will consider the lessons, such as those about single rooms, maintenance schedules and the kind of maintenance that should be done, and the design at the outset, which should allow for a better balance between energy efficiency and the right air flow, particularly for groups of patients who are immunosuppressed.

“The design of a building such as the Queen Elizabeth university hospital needs to be capable of being flexed depending on the particular needs and vulnerabilities of different patient cohorts. That has to be a key lesson even of this review, far less what the public inquiry will teach us.”

Labour’s Monica Lennon asked for an assurance that the terms of the public inquiry will allow proper scrutiny of the decisions that were taken by the Government and successive ministers in respect of the QEUH and the Royal hospital for sick children in Edinburgh?

She said: “Notwithstanding the cabinet secretary’s comments about family engagement, some families are feeling quite upset and let down by the process so far, and they feel that there has been a cover-up. What is her response to those families?”

However, Ms Freeman denied this. She said: “There has certainly been no attempt by me to cover up anything in that regard. We have taken a number of steps to ensure that families are heard and that when they have shared concerns, those concerns are addressed.

“That is Professor White’s daily role and has been for a number of weeks. Where there are individual family issues around a child’s case, such as how the case has been managed and whether there was an impact on the management or treatment of the child, and for those tragic cases in which a child died as a consequence of the environmental issues, we have also taken steps to ensure that the independent case review has a clear determination to work with a level of family engagement that the families determine themselves.”

She added: “Lord Brodie has been clear from the outset that he wants to personally hear from families directly about their concerns and issues. As I also said, the draft remit, which he was content with, was circulated for comment to families who are engaged with and affected by issues at the children’s hospital at the Queen Elizabeth university hospital, and those comments were incorporated into the final remit that we will publish. A great deal of work has gone on to ensure that that all happens.

“How Lord Brodie conducts his inquiry is of course entirely for him. It is a statutory inquiry with a number of significant powers. He was thoughtful before agreeing to chair the inquiry, because he is determined to get to the bottom of a number of issues that he has already identified as needing to be drilled down into.

“That includes the role in decision making of Government, and he will consider and conclude whether that has been appropriate or whether mistakes have been made and failures have occurred. I am certain that he will pursue his public inquiry without fear or favour and in the manner that he thinks is correct. I cannot tell him how to do it, and I would not dream of doing so. He will get on and do it.”

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