Queen Elizabeth University Hospital – subject of extensive inquiries and reviews.
By Bill Heaney
The Health Board in charge of the Queen Elizabeth University Hospital and Royal Hospital for Children, both of which serve Glasgow and West Dunbartonshire, has once again apologised for “the current issues” associated with these two hospitals.
The Board met this week for an update to consider some key ongoing issues in respect to the series of independent reviews of the QEUH and RHC sites, specifically:
One of the “current issues” involves the death of a ten-year-old girl, Milly Main, who died after contracting an infection at the £850 million showpiece hospital campus in 2017.
A review, chaired by Court of Session judge, Lord Brodie, set out last August to examine the issues there and at the new Royal Hospital for Children and Young People in Edinburgh.
Milly’s death is also being investigated by prosecutors to whom NHS Greater Glasgow and Clyde have passed details of its investigation into her death to the procurator fiscal in February.
Milly Main died after contracting an infection at the Royal Hospital for Children.
Milly was being treated at the Royal Hospital for Children in Glasgow, which is part of the Queen Elizabeth University Hospital campus (QEUH).
Kimberly Darroch believes her daughter’s death was due to contaminated water at the hospital, but claimed her family were being kept “in the dark” when they asked for details from the hospital authorities.
Milly had leukaemia from the age of five, but was in remission before contracting the infection at the QEUH.
She died in August 2017, with her death certificate listing a stenotrophomonas infection of the Hickman line – a catheter used to administer drugs – as a cause of death.
The family say they were not told about the link to contaminated water problems at the hospital.
Ms Darroch, 36, said at that time: “Nearly three years since Milly died, we feel the heart-breaking loss of our daughter every day and feel we’re still in the dark about her death.
“Having been let down by the Health Board, we hope the public inquiry will uncover the truth about what happened at the hospital – not just for us but for all the families affected, and to ensure no other family ever has to go through what we went through.”
Anas Sarwar, the recently elected leader of Scottish Labour, was asked to help Milly’s family and the relatives of others. He said: “Families must be at the heart of the investigation.
“There is a huge amount of pressure on this inquiry, which must deliver answers for parents, patients and the public.
“The catastrophic failures at the QEUH, and the associated problems with the Sick Kids in Edinburgh, are a national tragedy.”
Mr Sarwar said there had been a loss of public trust over the issues and the “success or failure” of the inquiry depended on “getting answers for Milly’s parents and all the families affected”.
Labour leader Anas Sarwar with Milly Main’s mother Kimberly Darroch.
NHS Greater Glasgow and Clyde apologised for their failure to provide Milly’s family with satisfactory responses to the questions that remain unanswered for them and recognise the additional distress this has resulted in.”
An independent review by Health Protection Scotland into the water supply confirmed contamination of the system in 2018.
Chief executive, Jane Grant, said the Health Board remains on Level 4 of the NHS Scotland Performance Management Framework in respect of on-going issues around the systems, processes and governance in relation to infection prevention, management and control at the Queen Elizabeth University Hospital (QEUH) and the Royal Hospital for Children (RHC) and the associated communication and public engagement issues.
She said that, as part of the escalation process, an Oversight Board was established, chaired by Professor Fiona McQueen, with three sub groups reporting to it, namely Infection Prevention and Control Governance, Communication and Engagement and a Technical group.
Ms Grant, pictured right, added: “The Health Board has worked closely with the Scottish Government team throughout, providing significant amounts of evidence over the months to the sub groups, reviewing and commenting on draft reports.”
Reports were published on 22nd March 2021, with families receiving a copy of the Casenote Review in advance of its publication.
“The Health Board would again wish to apologise sincerely for the distress and concern that these issues have brought to our patients, their families and staff.
“There is a clear appreciation of the very challenging circumstances that our patients, their families and our staff have had to face during this difficult time and it is essential that we address these reports in a proactive and positive manner to ensure patient safety remains at the heart of our endeavours and that, where improvements are required, we address them swiftly and systematically.
“It is also essential that we ensure that we have learned from this difficult set of circumstances to minimise the risk to all our patients, in whatever area of the Health Board they are being treated in the future.”
An Oversight Board had addressed its work through a review of key documents and direct inquiry with colleagues within he Health Board over many months.
This included the examination of the Health Board internal minutes and papers, specially commissioned papers on individual topics, material provided to the Scottish Government by some THE HEALTH BOARD clinicians and microbiologists and a number of key external documents.
The Oversight Board report sought to address four questions:
- To what extent can the source of the infections be linked to the environment and what is the current environmental risk?
- Are IPC functions “fit for purpose” in the Health Board, not least in light of any environmental risks?
- Is the governance and risk management structure in the Health Board adequate to pick up and address infection risk?
- Has communication and engagement by the Health Board been sufficient in addressing the needs of children, young people and families with a continuing relationship with the Health Board in the context of the infection incidents?
With regard to the first question, the Report indicates that, in the absence of definitive sources, the strong possibility of a link is “undeniable”.
It outlines that the cases “did not necessarily suggest a pattern at first” and water testing before 2018 did not provide evidence of contamination.
However, by 2018, there was significant evidence of a succession of environmental defects and the Health Board was taking action to address the issues.
Ms Grant said: “The ‘timely, robust and focused’ response by the Health Board to water contamination was commended within the Report.
“The report also states that the Health Board, national bodies and the Scottish Government lacked a strategic understanding of the complexity of the water contamination and that environmental risks associated with hospitals are now better understood overall, not least through the efforts of the Health Board, which provide a platform for further learning and improvement in the future.
“With regard to the current environmental risk, the report states ‘Given the water testing results, the chemical dosing system appears to have proven effective.
“Whilst unusual environmental bacteria can occur in all healthcare settings, the risk must continue to be monitored, evaluated, mitigated and reported’.
“The Board was quick to react to individual incidents with clear IPC actions and had the ability to take highly challenging steps, to address any risk to the care and safety of the patients.”
She added: “The ability to see and act on a wider perspective framed by environmental risks and infection incidents, was not apparent.
“Issues were also raised in relation to the functioning of the Incident Management Team meetings and their short term reactive response was noted.
“However, it is also stated that a number of more significant decisions, such as the introduction of chemical dosing, were taken and this is recognised as being ‘exemplary’.
“It is also notes that relationships between the Infection Prevention and Control team and key services, such as Estates and Facilities and, between, and among, microbiologists at the QEUH were fraught and compromised effective working.
“Significant work has been undertaken since then and the Estates and Facilities interface with the infection control team has been strengthened and is now working in a more effective manner.”
This is the case also in relation to the section on governance and risk, the size and complexity of the Health Board is outlined as a challenge in ensuring cross-cutting issues are addressed across the whole governance system.
Ms Grant said: “It commends the work that has already been put in place to make a number of changes, particularly with regard to the issues within Estates and Facilities, where the appropriate operational governance processes had not been followed in the past.
“Further sections outline the fact that there was good evidence of assurance on the actions being given, but there was less evidence of challenge apparent from the Oversight Board’s desk-top examination of the minutes of meetings.
“The approach to Risk management, specifically the description of risks, was considered to require review, although the Report notes that a different approach to recording risk would not have led to a different course of action to respond to, or mitigate, the risk.”
Having regard to communication and engagement, there was substantial evidence of a compassionate approach to communication by frontline staff, but stated that communication at a corporate level was inconsistent and some patients and families considered that questions about episodes of infection were not answered in a timely or informative manner. Fuller consideration could have been given to psychological harm in the application of the organisational duty of candour.”
A considerable amount of work is said to have already been done, or is underway, to address these issues.
A review published on 22nd March 2021 was commissioned by [Jeane Freeman] the Cabinet Secretary for Health and Sport in January 2020 to be undertaken by a panel of independent experts, led by Professor Mike Stevens, Emeritus Professor of Paediatric Oncology from the University of Bristol.
Its purpose was to determine how many children and young people with cancer, leukaemia and other serious conditions were affected by a particular type of serious infection caused by Gram-negative environmental bacteria, from 2015 to 2019; to decide, as far as it is possible to do so, whether the infections were linked to the hospital environment, and to characterise the impact of the infections on the care and outcome of the patients concerned. It involved the consideration of the cases of 84 children and young people who fell within the relevant criteria.
Its findings indicate that they were unable to identify evidence that unequivocally provided a definite relationship between any infection episodes and the environment.
However, the report also states that 34% of the infections might be, on the balance of probability, reasonably considered to be “Most Likely” linked to the environment. It also provides an assessment on the impact of the infections on the individual patients
There was an increased likelihood that the infections within the “Most Likely” group occurred in 2018 and that there was significant action taken by the Board at that time, with external support from Health Protection Scotland and the Scottish Government.
Ms Grant said: “It acknowledged the steps taken by the organisation to respond to what was an extremely challenging and complex situation.
“It commends the Health Board in a number of areas, including the comprehensive and detailed clinical records kept by the medical and nursing teams and the good communication between the microbiologists and the haematology oncology team in relation to the diagnosis and management of infections.
“It is also states that communication with patients and their families was generally well documented and of a high standard, despite some patients raising concerns in this respect.
“The Review also commends the significant work undertaken by the Quality Improvement Group established in 2017 to reduce the level of central line associated infection which currently remains low. “
Work continues to review the actions arising from the report of the independent review of infection control concerns at the QEUH and the RHC by Dr Andrew Fraser and Dr Brian Montgomery.
Lord Brodie’s inquiry, referred to earlier, has issued “core participants” with formal evidence requests focused on the priorities outlined below:
- Adequacy of ventilation, water contamination and other matters adversely impacting on patient safety and care.
- Governance and Project Management – as far back as 2002.
- Effects of the issues identified on patients and their families.
The first formal meeting took place on Thursday 18th March 2021 which was an initial gathering of the legal representatives of core participants, at which Lord Brodie, pictured right, explained the progress of the Inquiry and the programme going forward.
A hearing will take place on Tuesday 22nd June 2021. This will be a procedural hearing to confirm arrangements for the first substantive hearings in September 2021. The first substantive hearings of the Inquiry will commence on Monday 20th September 2021 and will last for three weeks.
Ms Grant The focus of this first set of hearings is to enable the Inquiry to understand the experiences of affected patients and their families and it is those patients and families who will form the core of those called upon to give evidence in person at the initial hearings.
“It is likely that the next set of hearings will be scheduled for late 2021 /early 2022, with a procedural hearing ahead of that time. Further details of what will be covered and the programme for the hearings will be published in due course, however it has been indicated that the initial focus will be on the inquiry into the Royal Hospital for Children and Young People in Edinburgh.”
Further to the approval of the Board in January 2019 to raise Court Proceedings against the parties responsible for delivering the QEUH/RHC construction project, the Health Board engaged MacRoberts LLP to act on its behalf.
The legal debate has been set for June 2021, to be heard by Lady Wolffe.
The many issues described in this paper represent a significant amount of work over the coming months, and indeed years in respect of the Public Inquiry.