Queen Elizabeth University Hospital: case note review - overview report

11. References and Resource Material

This chapter lists the documents to which we had access. Not all turned out to be relevant but we list them here for completeness. Not all documents were dated or had an identified author / origin.

Section 1 relates to documents that are principally internal to NHS GGC and are ordered within themes.

Section 2 summarises external documents/reports and are listed against the originating organisation.

In addition, we held meetings with individuals and groups of individuals (see Appendix A) and generated, received and saw many emails; all of this activity provided additional and/or complementary information.

Section 1

11.1 Environmental Microbiology

Water Sampling

Potable Water Master Files: 2015/2016/2017/2018/2019

Positive results: January-March 2017

QEUH DMA Sample Results: 2017

TPATH Master Record:2017

Potable water- combined TPATH & DMA- final version for GGC Review: 2017

QEUH DMA Sample results: 2018

TPATH Master Record: 2018

QEUH DMA Sample Results: January-June 2019

QEUH DMA Sample Results: July-December 2019

Potable Water- combined TPATH & DMA Data- Final draft for GGC Review: 2019

QEUH DMA Sample Results Retained: 2019

Sampling Schedule- QEUH Campus: 2020

Water Flushing

SOP Weekly Water Flushing Review: 25 February 2020

Water Flushing Record Supervisors Report: November 2020

QEUH & RHC Ward Flushing Record examples: November 2020

Water Flushing Compliance Record: 9 November 2020

Water Flushing Compliance Record: 16 November 2020

Water Flushing Compliance Record: 24 November 2020

Water Flushing Compliance Record: 01 December 2020

QEUH Water Flushing Tool Box Talk Domestic Services - 16 March 2020

Water Risk Assessments

Risk Assessment pre-Occupancy L8 Risk Assessment - 2015

Risk Assessment Water Supply: March 2015

Risk Assessment Water Safety: August 2016

Risk Assessment Water Safety- Draft: April 2017

Risk Assessment Water Safety- version 4: July 2017

Risk Assessment Water Safety pa v6 Interim report: June 2018

Water Policies

NHSGGC SOP for Minimising the Risk of Pseudomonas Aeruginosa Infection from Water. Versions dated: 2015, 2017, 2018, 2019

Controlling the Risks of Exposure to Legionella & other harmful bacteria. Written scheme: 2019

External Reports

2015 DMA Report (version 3)- Review of recommendations and actions arising from the Draft meeting report by Dr Susanne Lee, Leegionella Ltd - 25 April 2018

Investigation into Contamination of flow straighteners - 11 July 2018

Reports on water systems at QEUH and RHC - ‘Pre-occupancy risk assessment’: published 16 December 2018

2015 DMA Report (version 3)- Further review of recommendations and actions arising from the reports on water systems at QEUH and RHC (version 3) - ‘Pre-occupancy Risk Assessment’: published 29 November 2019

Hard Surface

Hard Surface samples- master file: 2015-3 March 2020

6A Hard Surface samples: 1 June 2019-23 December 2019

Other

6A Air Samples: 1 June 2019-19 December 2019

11.2 Microbiological Typing

Standard

2015 Referred Gram negative isolates QEUH (inc. Water). Complete Final Record 16.12.20

2016 Referred Gram negative isolates QEUH (inc. Water). Complete Final Record 16.12.20

2017 Referred Gram negative isolates QEUH (inc. Water). Complete Final Record 16.12.20

2018 Referred Gram negative isolates QEUH (inc. Water). Complete Final Record 16.12.20

2019 Referred Gram negative isolates QEUH (inc. Water). Complete Final Record 16.12.20

Master Timeline – Gram negative blood cultures updated May Nov 2019

Timelines for selected cases (GGC fingerprinting)

Whole Genonome Sequencing (WGS)

Stenotrophomonas spp. WGS files 2020

Enterobacter spp. WGS files 2020

Cupriavidus spp. WGS files 2020

11.3 Facilities Maintenance Work

FMT Audits RHC ward 2A Audits: 2015-2018

FMT Audits QEUH ward 6A Audits: 2018-2019

HAI-SCRIBEs: 2016-2018

HAI-SCRIBEs: 2019

Completed Estates work (old data): 2015-2019

HAI-SCRIBE (old data)- Risk Assessment of work done

6A Maintenance Data: January 2019-October 2020

Domestic FMT Scores: 2015-2018

Estates FMT Scores: 2015-2018

FMFirst Information Ward 2A: 2015-2018

SCRIBE Summary Document: 2016-2018

Ward 2A & 2B Floor Plan

Ward 2A Data final- Facilities Monitoring Tool Information: 2015-2018

Ward 6A Data final: 2018-2020

11.4 Infection Prevention & Control Activity

IPCAT audits

2016 - 2A/2B- Audits

2017 - 2A/2B- IPCAT Audit Actions

2018 - 6A-IPCAT Audit Actions

2018 - 6A- Audits

2018 - 2A- IPCAT Audit Actions

2018 - 2B- IPCAT Audit Actions

2019 - QEUH 6A DCU (RHC 2B) IPCAT Actions

2019 - QEUH 4B BMT IPCAT Actions

2019 - QEUH 6A (RHC 2A) IPCAT Audit Actions

SICP audits

2015 – 2019 Hand Hygiene audits

Ward 2A- Weekly ward reports:

2017 May – October, and December

2017 September SICP Action Plan Completion report

2018 January, March - August

Ward 6A

2018 December

2019 March, May, September, November and December

Ward 6A CAIR Report- Audit of IC Standards (Scoresheet): October 2019

CIP Action Plan Completion: 16 December 2019

Ward 6A CAIR Report: December 2019

Enhanced Supervision audits

2017- Ward 2A

Master Enhanced Supervision - template

June, July

2018- Ward 2A

March – December

2019- Enhanced Supervision Ward 6A (ward 2A) Audits

January - April

August - December

Copy of 6A Walk Round: 6 August 2019

Hand Hygiene Audit Summary Report

11.5 IMT & related Activity

2016 Meetings:

PAG-HAI Asperguillus cases in paediatric haematology: 4 August 2016

IMT Aspergillus Schiehallion IMT minutes: 5 August 2016

NHS GGC HAIORT Aspergillus Royal Hospital for children - Incident form: 5 August 2016

Timeline April v2: August 2016

Aspergillus email: 16 August 2016

Acinetobacter baumanii in Ward 1a-: 28 June 2016

Summary of HIIORT: 2015-2019

2017 Meetings:

Appendix 4- Summary of Incidents & outbreaks on ward 2A: 1 March 2017- May 2017

PAG increase in fungal pathogens in Haematology: 3 March 2017

Minutes- IMT Aspergillus Ward 2A: 7 March 2017

PAG: 12 April 2017

IMT minutes action points ward 2A Rotavirus: 13 April 2017

Minutes Ward 2A Rotavirus Astro Virus: 17 April 2017

PAG-URE 2A: 28 April 2017

Line listing v ward 2A, RHC: April 2017

PAG- Norovirus 2A: 31 May 2017

Stenotrophomonas (1): 26 July 2017

PAG Aspergillus Ward 2A RHC: 27 October 2017

NIPCM Debrief report VRE Rotavirus Astrovirus final

2018 Meetings:

Final PAG Cupriavidus: 15 February 2018

IMT Water Contamination Ward 2A: 2 March 2018- 27 March 2018

Healthcare Infection Incident & outbreak reporting (2): 1 March 2018

VRE PAG Ward 2A: April 2018

PAG E Cloacae final: 18 May 2018

PAG Increased incidence - Enterobacter Cloacae in Blood Cultures: 18 May 2018

PAG Increased incidence - Stenotrophomonas maltophilia in blood cultures: 18 May 2018

IMT Water Contamination Ward 2A: 29 May 2018

Healthcare Infection Incident & outbreak reporting: 4 June 2018

IMT Water Contamination Ward 2A: 4 June-21 June 2018

PAG Aspergillus final: 20 July 2018

IMT x3 Gram Negative bacteraemia associated with Haemoncology patients Ward 2A: 5 September 2018, 10 September 2018 & 13 September 2018

Weekly summary information: 5 September 2018 & 12 September 2018

IMT Action list - 5 September 2018-13 September 2018

IMT Water Contamination Ward 2A: 14 September -28 September 2018

Ward 6A pre Decant inspection completed on 21 September 2018

October- IMT Water Contamination Ward 2A: 5 October-26 October 2018

IMT Water Contamination Ward 2A: 2 November: 30 November 2018

Communication with patient families and staff as a result of IMT actions in 2018- 2 March 2018. 30 November 2018

PAG Cryptococcus neoformans: 18 December 2018

2019 Meetings:

Ward 6A weekly shower checks 28 January 2019

PAG- Gram Negative 6A: April-May 2019

PAG-Steno cases: April- May 2019

IMT Ward 6A Gram Negative Blood Cultures: June - November 2019

IMT Action list (version 2): 19 June - 25 June 2019

IMT Action List: 19 June - 25 June 2019

IMT Teleconference notes ward 6A Gram Negative blood cultures: 20 September 2019

Communication with patient families and staff as a result of IMT actions in 2019

IMT PICU Pseudomonas Aeruginosa: 19 November 2019

Water Group Meetings:

Monthly meeting minutes from April - December 2018

Monthly meeting minutes from January - December 2019 (excluding May & November)

QEUH Campus Water Systems Written Scheme - Controlling the Risks of Legionella &n other Harmful bacteria in Water Systems - NHS GGC & QEUH Oversight Board report. 2019

QEUH Water Sampling Programme 2020, version 4 - NHS GGC & QEUH Oversight Board report

Risk Assessment Water Safety (interim report): 6 June 2018

NHSGGC Water Actions & reviews: 2015-2019

Water Testing in QEUH Campus 2015-2017

HIIATS:

HIIATS Red & Amber RHC 2018 - 2020

HIIORTS:

Review of Healthcare Infection Incident & Outbreak Reporting Templates (HIIORTS) 2015 -2019

Hot Debriefs:

Hot debrief - Serratia Marcescens Outbreak report NICU- March 2011

Hot debrief - Outbreak Report completed: 12 May 2016

Hot debrief - Outbreak Report PICU RHC: 27 October 2016

Hot debrief - Rota Astro ward 2A: April 2017

Hot debrief - Aspergillus- March: April 2017

Hot debrief - March/April 2018

Hot debrief - Stobhill GAS: 19 February 2019

Hot debrief - Ortho SSI Rates: 29 July 2020

Hot debrief - PRM MSSA 2019 (final draft): 30 July 2020

Root Cause Analyses (RCA)

Root cause analysis of gram negative bacteraemia in a cohort of paediatric Haematology/oncology patients at the Royal Hospital for Children, October 2019.

Template RCA document for Haem Onc 2019

Completed examples of RCA: 2019 (2); 2020 (10)

Other IMT’s

Meeting records for Cryptococcus December 2018-February 2019

Analysis Documents and Other Data

NHSGGC report on IPC response to 2017 Infections in RHC

Indexed comparison of changes in bed days haem/onc v Rest of RHC: July 2013- July 2018

Descriptive Analysis of Five year trends in bacteraemia rates for selected Gram Negative Organisms: July 2013-July 2018

Bacteraemia rates and Resistance Paediatric Haemato –oncology 2014 -2018- Dr Christine Peters & Kathleen Harveywoods

QEUH Sampling OOS Parameters IP- Microbiological monitoring QEUH/RHC during & post chlorine dioxide installation: 20 November 2018- Dr Teresa Inkster

Timeline with Reference to HFS Water Management Issues Technical Review- NHSGGC-QEUH & RHC- 2018

Timeline of Events & Actions relating to RHC wards 2A/2B Water Incident: March- November 2018

RHC Gram Negative Descriptive Epidemiology- Dr Iain Kennedy July 2019

PHPU Epidemiological Curve & Summary of Organisms- updated: July 2013-September 2019

SBAR 6A Incident Data & Epidemiology – Dr Teresa Inkster & Dr Christine Peters: 7 October 2019

SBAR- Review of 2017 Mortalities in which Stenotrophomonas was isolated, by Alan Mathers, Chief of Medicine, W&C - November 2019

Report on the Clinical aspects of the management of patients with documented Blood stream infection with an environmentally classified Gram Negative organism in the Paediatric Oncology Service, NHSGGC between June 1st 2015 and September 30th 2019. - TJ Beattie, January 14 2020

NHSGGC Infection Control presentation: 16 January 2020

Paed Haem-Onco SPCs Blood Cultures: 5 August 2020, by Ann Kerr

SPC Charts Gram Negative Blood Cultures Paediatric Haem-Onc: August 2020

Paediatric- Haemato-Oncology (QEUH 6A & 4B BMT)- Blood Cultures- Gram Negative Environmental Bacteria Group & Environmental Enteric Bacteria Group: September 2020, by Ann Kerr

SPC Chart- Gram Negative RHC/QEUH- Paediatric Haemato-Oncology blood cultures: October 2020

Policies

NHSGGC Outbreaks in Hospitals- versions dated: November 2015, 2017, 2019, 2020 (v9)

NHS GGC SOP Environmental Organisms in High Risk Areas. November 2018 (final v1)

11.6 Clinical Care

Central Line Care

Audit report: Gram Negative Sepsis & CVL Removal

Rate of Central line associated blood stream infections (CLABSI) per 1000 central line days- updated to December 2020

Antibiotic Policies and Practice:

Management of Neutropenia & Fever Antibiotic Policy 2010, 2015, 2017, 2020

Clinical Guideline- Empirical Antibiotic Therapy in Children, November 2017

SBAR- Review of Prescribing in Haemato-Oncology Patients RHC Glasgow: 12 December 2019

Adverse Events

Datix system reports for cases included in the Case Note Review

NHS GGC Policy on the Management of Serious Adverse Events: August 2020

Information about Deaths

Death certificates (19 patients)

NHS GGC PRAM / Morbidity & Mortality Meeting reports (17 patients)

NHS GGC Guidelines for Morbidity & Mortality Review Meetings

NHS GGC M&M participant Analysis Tool

NHS GGC M&M Principles of Practice- Code of Conduct- paper by Karon Cormack, Head of Clinical Risk

NHS GGC Morbidity & Mortality Review Process - January 2018

NHS GGC Morbidity & Mortality Reviews, An analysis

Other

Clinical Review Group Terms of Reference

Ward 6A Reopening Bundle: 8 November 2019

CRG Minutes Ward 6A: 17 February 2020

Episodes of care- Transferred to other wards/hospitals/Health Boards for delivery of Chemotherapy – July–November 2019.

Section 2

11.7 Health Facilities Scotland:

Water Management Issues Technical Review-NHSGGC-QEUH & RHC. March 2019

SBAR for Health Facilities Scotland Water Management Issues Technical Review report dated March 2019; published 19 February 2020

11.8 Healthcare Improvement Scotland:

Learning from Adverse Events through reporting & review - A national framework for Scotland - December 2019

Adverse Events: Guidance on national notification data - March 2020

11.9 Health Protection Scotland:

HPS Pseudomonas Guidance (Post Consultation):13 December 2012

Water Report - Summary of Incident & Findings of the NHS GGC: QEUH/RHC for Children Water Contamination Incident & Recommendations for NHS Scotland: 20 December 2018

Health Protection Scotland - Review of NHSGGC Paediatric Haemato-Oncology Data: October 2019

Mandatory NHS Scotland Alert Organism/Condition list: November 2019

Guidance for Neonatal Units (NNUs) (Levels 1,2 & 3) adult & Paediatric Intensive Care Units (ICUs) in Scotland to Minimise the risk of Pseudomonas Aeruginosa infection from water 2018

Pseudomonas aeruginosa routine water sampling in augmented care areas for NHS Scotland- Report by Health Protection Scotland September 2018

Prevention and management of healthcare ventilation system-associated infection incidents/outbreaks – 16 October 2019

Prevention & Management of Healthcare Water Associated Infection Incidents/Outbreaks: August 2019 v1.0

HPS Infection Incident Assessment Tool

11.10 NHS Scotland

The Risk Management of HAI: A Methodology for NHS Scotland- Healthcare Associated Infection Taskforce, November 2008

National Infection Prevention & Control Manual- Healthcare Infection Incidents, Outbreaks & Data Exceedance- http://www.nipcm.scot.nhs.uk/chapter-3-healthcare-infection-incidents-outbreaks-and-data-exceedance/#a1744

11.11 Other Healthcare Reviews:

The Vale of Leven Hospital Inquiry Report- November 2014

QEUH Independent Review- Review report- Fraser & Montgomery- June 2020

Terms of Reference for the Brodie Inquiry: June 2020

11.12 Oversight Board

Procedures in the event of out of specification sample for Legionella & other

monitored bacteria, moulds etc- NHS GGC & QEUH Oversight Board report

Timeline of Incidents for period 2015-2019 (‘Super Timeline’) 2020

NHSGGC Oversight Board Infection Prevention & Control & Governance Subgroup- Report of the Peer Review: June 2020.

NHSGGC- QEUH Oversight Board- Management of Infection Control Incidents in Wards 2A/RHC during 2017. 31 August 2020

The QEUH/NHS Greater Glasgow & Clyde Oversight Board- Interim Report: Progress & Findings- December 2020