HOSPITAL DEATHS: Any journalist of the least merit and experience knows instinctively that what is to follow is a whitewash or a cover-up.

When you read a headline such as the one below on this press release, any journalist of the least merit and experience knows instinctively that what is to follow is a whitewash or a cover-up, especially under this SNP government we have in Scotland today.

It happened in the past with the Catholic Church in Scotland with the MacLellan Report on Clerical Child Abuse and it is happening today with the local health board’s official report on the scandalous situation at the Queen Elizabeth University Hospital which, with the Royal Children’s Hospital, serves West Dunbartonshire and Argyll and Bute.

There are no photographs attached by the Board spin doctors or cleverly worded quotes to encourage newspapers to publish the contents of the release because, in truth, that is the last thing the Health Board wants to happen. The word “deaths” is nowhere to be seen. Nor is there any indication of what this report cost to produce.

Here is that headline and the contents of the press release: 

NHSGGC statement in response to
Oversight Board Report and Case Note Review

The reports published today cover an extremely challenging situation as we investigated and responded to unusual infections in young patients and the possibility that these infections were linked to the environment.

The reports highlight a number of significant issues for the Board.  We fully accept that there is important learning for NHSGGC and are committed to continuing to address the issues within the reports.

This has been an incredibly difficult period for patients, families and staff and we are very sorry for the distress caused.   For those whose infection episodes were judged by the Case Note Review panel to be possibly or probably linked to the hospital environment, we apologise unreservedly.

The question over potential links between the hospital environment and infections amongst young patients treated in RHC haemato-oncology unit has persisted for a number of years. As the two reports published today have highlighted, this has been a very difficult question to answer.

Whilst it has not been possible to provide conclusive answers to these questions, significant action has been taken to mitigate the risk of infection from the environment.  As soon as we recognised the potential risks with the water supply in 2018, we took action. This included point of use filters for water outlets, chlorination treatment of the water supply, and ultimately the relocation of Wards 2A and B to another part of the hospital.

In total, £6 million was spent on addressing water supply issues.  In addition, a further £8 million has been invested in Wards 2A and B, including a significant upgrade of the ventilation system. This will deliver the one of the safest clinical environments within the UK and with the improvements that have already been made and continue to be made, infection rates at the hospital remain low.

Over the past year we have also worked closely with the Oversight Board and with Professor Angela Wallace, appointed by the Scottish Government as Interim Director of Infection Prevention and Control.

We have reviewed and strengthened our infection control and protection arrangements including the development of stronger relationships between the Infection Prevention and Control team and microbiologists. We have also worked to build and develop the Board’s communications and engagement with patients and families.

We are encouraged to note that the work to date has been endorsed by the Oversight Board.

There is undoubtedly further important learning for NHSGGC and for Scotland as a whole, from the unprecedented circumstances that we faced.  We are fully committed to continuing to improve and to implementing the recommendations from these reviews.

Jane Grant, Chief Executive of NHS Greater Glasgow and Clyde, and John Brown, Chief Executive.

Jane Grant, Chief Executive of NHS Greater Glasgow and Clyde, said: “This has been a very challenging time for patients, families and staff and I am truly sorry for this. For families, children and young people, undergoing cancer treatment is already an incredibly difficult situation and I very much regret the additional distress caused.

“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.

“I would like to thank our staff who have worked so hard in difficult circumstances to deliver quality care, putting our young patients and their family at the centre of everything they do.

“With the improvements that have already been made and that continue to be made, infection rates at the hospital remain low.  Patients and families can have confidence in the care they receive and in the environment within which they receive it.”

Speaking on behalf of her clinical colleagues, Professor Brenda Gibson, Lead Clinician, Haemato-Oncology, said: “Throughout this exceptionally difficult period, our clinical team has been, and remains, entirely focused on caring for and supporting our young patients and their families.

“Person-centred cancer care involves a partnership between staff and families and we are committed to maintaining and developing strong relationships with parents and carers as we move forward.”

Professor John Brown CBE, chairman, added: “On behalf of the Board, I offer my sincere apologies to all the children and families who have been affected by these issues.  The Board continues to take this situation very seriously, and has welcomed external support and advice as we have worked to understand, and respond to, an unprecedented set of circumstances not previously faced in the NHS.

“These reports provide further opportunity for improvement and learning for NHSGGC and we are fully committed to that course of action.”

Cllr Jonathan McColl, who is leader of the SNP administration on West Dunbartonshire Council, an SNP candidate for the Scottish Parliament, and a member of the Health Board which was in charge during this crisis, refuses to comment to The Dumbarton Democrat.
 
The release ends inviting the press to read the reports. You can find them here

Queen Elizabeth University Hospital – Case Note Review Overview Report

The Queen Elizabeth University Hospital/ NHS Greater Glasgow and Clyde Oversight Board: Final Report

This, however, was the report that appeared in today’s Daily Record:

Contrast and compare. This is a more accurate reflection of what happened at this hospital.

Glasgow’s Queen Elizabeth University Hospital slammed for ‘significant failings’

The Scottish super hospital was criticised in a review led by Professor Mike Stevens

A Scots hospital has been blasted for “significant failings” over infection prevention and control, governance and risk management, according to a new report.

The Queen Elizabeth University Hospital (QEUH) in Glasgow was criticised in the review led by Professor Mike Stevens.

His survey investigated 118 episodes of serious bacterial infection in 84 children and young people who received treatment for blood disease, cancer or related conditions at the Royal Hospital for Children.

It found a third of these infections were “most likely” to have been linked to the hospital environment and that two of the 22 deaths were, at least in part, the result of their infection.

Health Secretary Jeane Freeman said: “Patients and their families should not feel unsafe in our hospitals, and staff should not be afraid to speak out as whistle-blowers if they have serious concerns.

“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.”

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.

A third of infection episodes were rated as having a severe or critical impact on patients.

The expert panel has made 43 recommendations, including improvements in environmental surveillance and how water sampling and testing are used.

Individual reports will be prepared for the families of those patients affected by the infections at the QEUH.

They will also have the opportunity to meet with a member of the expert panel.

Jane Grant, chief executive of NHS GGC, said: “This has been a very challenging time for patients, families and staff and I am truly sorry for this.

For families, children and young people, undergoing cancer treatment is already an incredibly difficult situation and I very much regret the additional distress caused.

“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.

“I would like to thank our staff who have worked so hard in difficult circumstances to deliver quality care, putting our young patients and their family at the centre of everything they do.

“With the improvements that have already been made and that continue to be made, infection rates at the hospital remain low.

“Patients and families can have confidence in the care they receive and in the environment within which they receive it.” 

This was the report and headline that appeared on Monday in The Dumbarton Democrat:

HEALTH MATTERS: INFECTIONS LINKED TO GLASGOW CHILD CANCER HOSPITAL DEATHS

The Queen Elizabeth University Hospital campus opened in 2015

By Democrat reporter

An infection “probably” linked to the West of Scotland’s children’s hospital was the “primary cause of death” of a young cancer patient, BBC Scotland has learned.

Infections from contaminated water at the £1 billion hospital were also found to have been an “important contributory factor” in another child’s death.

A review looked into the cases of 84 children who developed infections while undergoing treatment at the hospital.  It found that a third of infections “probably” originated in the hospital.

And it said the rest were “possibly” acquired there.

The authors of the “case note review”, which should be published next week, said they recognised that some families would be disappointed that they could not have “greater certainty” about the links between their child’s infection and the hospital environment.

They said this was down to the limits of a retrospective review but also criticised the shortcomings in the data provided by the health board.

The review was commissioned by the health secretary Jeane Freeman as part of wider investigations into problems with the drainage and ventilation system at the £850m Queen Elizabeth University Hospital Campus, which includes the Royal Hospital for Children.

An official probe found “widespread contamination” in the water supply, with at least 23 children contracting bloodstream infections in the cancer wards in 2018.

The local health board was placed in “special measures” in November 2019 and in January last year two experts were appointed to oversee a review of infections.

Among them was 10-year-old Milly Main who died in August 2017.

Milly and mother
Milly Main, who died in August 2017, pictured with her mother, Kimberley Darroch.

Milly, who had leukaemia, underwent a successful stem cell transplant in July 2017 and was making a good recovery when the following month her Hickman line, a catheter used to administer drugs, became infected. Milly went into toxic shock and died some days later.

Her death certificate lists a Stenotrophomonas infection of the Hickman line among the possible causes of death but her mother Kimberley Darroch says the family were kept in the dark about a potential link to contaminated water problems at the hospital.

The health board previously insisted it was impossible to determine the source of Milly’s infection because there was no requirement to test the water supply at the time.

The case note review looked at how many children were affected by a particular type of serious infection caused by Gram-negative environmental (GNE) bacteria between 2015 and 2019.

It then looked to see whether it was possible to link these to the hospital environment.

The review does not name the children it investigated.

But it does say that one child was in the very early phase of a stem cell transplant and that a bacterial infection was the “primary cause of death”.

The review says that although disease progress was a major factor it judged that GNE bacterium was a “significant factor” in the cause of death. It says the infection was “probably” related to the hospital environment.

A further child death was noted to have occurred within six weeks of an infection episode. The bacterium was said to be “implicated” in the death. It was recorded as possible contributory factor in the death certificate.

The review looked at 84 children and 118 episodes of infection.

The report was critical of NHS Greater Glasgow and Clyde for not having a system in place that would have helped establish whether there was a link between bacteria in a patient and the place where they were treated.

Molly Cuddihy
Molly Cuddihy contracted a rare bacterial infection when she was undergoing cancer treatment three years ago.

In statement, Milly Main’s mother, Kimberley Darroch said: “There is nothing that can bring Milly back and a tiny part of me still hoped that the link to the water supply wasn’t true.  Finally we are starting to get answers after all these years.”

Professor John Cuddihy, whose daughter Molly survived a rare infection in 2018, told the BBC there had been significant failings on the part of management and leadership within NHS Greater Glasgow and Clyde.

He said they had failed to adequately protect vulnerable children who were exposed to additional risk while undergoing treatment for cancers.

Professor Cuddihy said the report had been made possible “due to the tenacity of families and those clinical staff who bravely exposed failings, at significant personal and professional cost”.

He said the report laid bare the impact of bacterial infection and the relationship with the environment at the hospital.

“This report identifies 84 cases and 118 episodes of bacterial infection- that’s 84 critically ill, vulnerable children that have been exposed to significant additional risk, which has affected them physically, psychologically and emotionally,” Professor Cuddihy said.

“Sadly, the report also highlights that two of those children who died did so, at least in part, as a result of their infection.”

 

 

Leave a Reply

%d bloggers like this: