QEUH Case Note Review and Oversight Board Report

Two reports have been published today highlighting significant failings in infection prevention and control, governance and risk management at the Queen Elizabeth University Hospital (QEUH).

The independent Case Note Review, led by Professor Mike Stevens, 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 that a third of these infections were ‘most likely’ to have been linked to the hospital environment, and that the deaths of two of the 22 children who had died were, at least in part, the result of their infection.

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.

While noting NHS Greater Glasgow & Clyde (NHS GGC) had made some improvements, the Expert Panel has made 43 recommendations to be taken forward, including improvements in environmental surveillance and how water sampling and testing are used to better inform investigations of possible links between clinical infections and water or environment sources. 

Individual reports will be prepared for the families of those patients affected by the infections at the QEUH, and they will also have the opportunity to meet with a member of the Expert Panel.

In addition, the Oversight Board chaired by former Chief Nursing Officer Professor Fiona McQueen has published its final report on infection prevention and control practices at the hospital, clinical governance and related risk management issues, and communication and engagement with patients and families.

The Oversight Board acknowledges NHS GGC has taken strong remedial action to find and address water contamination issues, however it found NHS GGC’s overall response was too short-term and reactive, and there were significant failings in governance, including infection numbers and building issues not being sufficiently escalated or acted upon.

It found substantial evidence of frontline staff taking a compassionate approach to communicating with families but that this had been inconsistently applied at a Health Board level. Some patients and families felt responses to their questions about episodes of infection were not timely or informative, and they were not presented with a full and accurate picture of what was happening. 

The Oversight Board’s final report recognises NHS GGC has taken a number of steps to address these issues, but concludes further work is required before it can be de-escalated from Stage 4 of NHS Scotland’s national performance framework.  

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. That is why I commissioned these reports alongside the Independent Review, NHS GGC’s escalation to Stage 4, and the Public Inquiry that is now underway, so that the issues raised could be fully investigated.

“These findings, which will inform the ongoing Public Inquiry, do not fault the quality of care provided by frontline NHS GGC staff, but they do highlight serious failings at the Health Board level. I agree with the Oversight Board’s conclusion that NHS GGC should remain at Stage 4.

“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.

“Ensuring that affected families are supported and fully engaged is of paramount importance, and in addition to the individual engagement the Case Note Review team will undertake with each family, it is very welcome that the Public Inquiry has appointed a Family Liaison Officer who will play an important role in ensuring full engagement and communication with families as the Inquiry progresses. The Scottish Government as a core participant is committed to assisting the Inquiry and respond to its findings and recommendations.  

“I am grateful to all members of the Case Note Review and Oversight Board for their dedication and diligence in conducting these reports, and also to the clinicians who originally raised these concerns for their assistance to the Oversight Board throughout this period.”

Professor Mike Stevens, Expert Panel Lead for the Case Note Review said:

“Central to our report is a concern for the safety of children and young people receiving treatment for cancer and serious blood diseases at the Royal Hospital for Children.

“Although serious infection is always a risk in those undergoing treatment of this kind, our investigations not only suggest a likely link to the hospital environment in a third of the episodes we reviewed, but have also allowed us to characterise the scale of the impact on the lives of the patients involved, and their families.

“We hope that our findings and recommendations will assist families in understanding the background to the infections experienced by their children and offer a way to reduce future risk by improving infection prevention and control in the future.”

Background

Queen Elizabeth University Hospital – Case Note Review Overview Report

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

The Case Note Review was commissioned by Health Secretary Jeane Freeman in January 2020. Led by Professor Mike Stevens, Emeritus Professor of Paediatric Oncology at the University of Bristol, the review team’s expert panel looked at all recorded bloodstream infections in children who received haemato-oncology treatment from the opening of the Royal Hospital for Children to the end of 2019, and whether these children were put at risk because of the physical environment in which they were cared for.

The Oversight Board was established by the Director-General of Health and Social Care in the Scottish Government and Chief Executive of NHS Scotland in November 2019 following escalation of NHS GGC to Stage 4 of NHS Scotland’s national performance framework.

This decision was taken in response to critical issues relating to the operation of infection prevention and control, governance, and communication and engagement with respect to the QEUH and the handling of infection incidents affecting children, young people and their families within the paediatric haemato-oncology service.

Chaired by former Chief Nursing Officer Professor Fiona McQueen, the Oversight Board consists of a group of experts and representatives drawn from other Health Boards, the Scottish Government and the affected families themselves.

The reports follow an Independent Review into the design, build, commissioning and maintenance of the QEUH and Royal Hospital for Children, which was published in June 2020.

An independent statutory public inquiry commissioned by the Health Secretary is also underway to review issues at the QEUH campus in Glasgow and the Royal Hospital for Children and Young People (RHCYP) in Edinburgh. The inquiry will determine how vital issues relating to ventilation and other key building systems occurred, and what steps can be taken to prevent this being repeated in future projects.