C.diff report condemns 'failures'
An inquiry into a deadly outbreak of Clostridium difficile at a hospital has revealed "serious personal and systemic failures".
The probe was set up in 2009 to investigate the treatment of 63 patients at the Vale of Leven Hospital in West Dunbartonshire between December 1 2007 and June 1 2008.
Inquiry chairman Lord MacLean published the report today, and it found C.diff was a factor in the death of 34 out of 143 patients who had tested positive for the infection at the hospital during the period January 2007 to December 31 2008.
Unveiling the findings at the Royal College of Physicians and Surgeons in Glasgow, Lord MacLean said patients had been badly let down by NHS Greater Glasgow and Clyde.
He said: "The inquiry has discovered serious personal and systemic failures.
"Patients at the Vale of Leven Hospital were badly let down by people at different levels of NHS Greater Glasgow and Clyde who were supposed to care for them.
"There were failures by individuals but the overall responsibility has to rest with the health board.
"The Scottish ministers bear ultimate responsibility for NHS Scotland and, even at the level of the Scottish Government, systems were simply not adequate to tackle effectively a healthcare-associated infection like CDI (C.diff).
"The major lesson to be learned is that what happened at Vale of Leven Hospital to cause such personal suffering should never be allowed to happen again."
Lord MacLean also expressed his view that the figure of 34 deaths is probably an underestimate as medical records were not available for all of the patients during the period in question.
There are 75 recommendations in the report covering areas including infection prevention and control, nursing and medical care and antibiotic prescribing.
Labour MSP for Dumbarton Jackie Baillie said: "Today is a day of mixed emotions for the families of those who lost their lives between 2007 and 2008. They were vindicated in their call for a public inquiry as the report identified significant failings at every level of the health service and government.
"The C.Diff outbreak at the Vale of Leven Hospital was the worst in the UK due to the high mortality rate.
"The families deserve nothing less than a full apology from the hospital management, NHS Greater Glasgow and Clyde and the Scottish Government for the mistakes which compromised patient care.
"What happened at the Vale of Leven should never be repeated anywhere in Scotland so it is vital we learn lessons and implement MacLean's recommendations in full."
Andrew Robertson, NHS Greater Glasgow and Clyde chairman, said: "On behalf of the Board and our staff, I would like to offer a full and unreserved apology to the patients affected and to the families who lost a relative to C.diff in the months between January 2007 and late 2008.
"This was a terrible failure and we profoundly regret it.
"I can give the firmest of assurances that, as a result of the lessons that have been learned, this could not happen again."
Chief executive, Robert Calderwood, said: "Re-iterating my personal apology I hope the relatives can take some comfort that the lessons learned from this outbreak have resulted in significant improvements in clinical practice, for instance, in more prudent prescribing of antibiotics.
"These major improvements introduced since the tragic events of six years ago have made the Vale and all of our hospitals in Greater Glasgow and Clyde safer for patients than they have ever been."
Newly-appointed Scottish Health Secretary Shona Robison has apologised to the patients and families affected.
She said: "Our first thoughts must be with the families and patients who have been let down by our NHS and for that I am truly sorry.
"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.
"Lord MacLean has provided a thorough, definitive and clear explanation of what went wrong at the Vale of Leven in response to the families wholly understandable call for answers.
"While NHS Scotland has moved on significantly in the intervening period, Lord MacLean's report gives us the further insight to ensure that the NHS does not fail patients and families as it did at the Vale of Leven."
She continued: "This report indicates a clear picture of the failings in the system that led to the C.diff outbreak. Its findings outline the lack of investment in the hospital, which was simply no longer fit for its purpose of providing modern health care. 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.
"At a national level there was no effective inspection regime at the time to pick up these failings and their impact on patient care. 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.
"The report found clear failings across all levels in the system - including nursing and medicine through to management.
"Given the findings we need to look closely at how we consistently ensure that we maintain high standards of care 365 days a year.
"Our top priority is that lessons are learned so that what happened at the Vale of Leven can never be allowed to happen again."
A full Scottish Government response to the report will be published in spring 2015.