Queen Elizabeth University Hospital/ NHS Greater Glasgow and Clyde Oversight Board: final report

1. Introduction

1. 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. Its aim has been to review and address the set of critical issues relating to the operation of infection prevention and control (IPC), governance and communication and engagement with respect to the Royal Hospital for Children (RHC) and the Queen Elizabeth University Hospital (QEUH) and the handling of infection incidents affecting children, young people and their families within the paediatric haemato-oncology service of NHS Greater Glasgow and Clyde (GGC). The Oversight Board was a direct consequence of the escalation of the Health Board to Stage 4 of NHS Scotland's National Performance Framework (as described more fully in the Interim Report).

2. The Oversight Board consists of a group of experts and representatives drawn from other Health Boards, the Scottish Government and the affected families themselves. Chaired by Scotland's Chief Nursing Officer, Professor Fiona McQueen, the work of the Board has been carried out through three Subgroups, each focusing on distinctive groups of issues.

• Infection Prevention and Control and Governance: this Subgroup has examined whether or not appropriate IPC and IPC governance was (and is currently) in place across NHS GGC in relation to these incidents and to recommend how to strengthen current approaches to mitigate avoidable infection harms. It was chaired initially by Irene Barkby MBE (Executive Director of Nursing, Midwifery and Allied Health Professionals in NHS Lanarkshire), and latterly by Scotland's Deputy Chief Nursing Officer, Diane Murray.
• Technical Issues: this Subgroup has focused on the technical operations of the hospitals in question, with a particular focus on key infrastructure issues, including the Board's approach to water safety. It has been chaired by Alan Morrison (Deputy Director for Health Infrastructure in the Scottish Government).
• Communication and Engagement: this Subgroup has considered effective communication with the children, young people and families of the paediatric haemato-oncology service of NHS GGC, as well as whether a wider, robust, consistent and reliable person-centred approach to engagement has been evident. It has examined the organisational duty of candour and other key review processes, such as the Significant Adverse Events Review (SAER) policy. It has been chaired by Professor Craig White (Divisional Clinical Lead, Healthcare Quality and Improvement Directorate of the Scottish Government).

The Terms of Reference for the Oversight Board and its supporting Subgroups are set out in Annex A.

3. The following Final Report sets out the findings, conclusions and recommendations arising from Oversight Board's programme of work from its establishment in December 2019 through to March 2021. The Oversight Board was supported by a number of special reports which were commissioned to examine specific issues relating to the Health Board, including:

• a timeline of infections and governance – this report set out a timeline of the incidents where a Gram-negative and other unusual bacteria (such as Mycobacterium Chelonae) were identified and which occurred in Wards 2A and 2B of the RHC and latterly in Wards 4B and 6A in the QEUH (the timeline is presented in Annex F);
• a review of NHS GGC's IPC governance, particularly with respect to escalation as part of outbreak management, by the IPC and Governance Subgroup;
• a review of NHS GGC water safety policy within the QEUH, undertaken through the Technical Issues Subgroup; and
• reviews of the Health Board's policy on Significant Adverse Events Reviews and Mortality/Morbidity Reviews, overseen by the Scottish Government's Directorate for Healthcare Quality and Improvement.

4. The work programme was also supported by a number of key individuals who worked alongside and within NHS GGC to support specific aspects of improvement:

• Professor Marion Bain (Deputy Chief Medical Officer, Scottish Government), who was appointed as the Executive Lead for Healthcare Associated Infection (HAI) within NHS GGC in December 2019 to set the strategic direction for IPC improvement (jointly reporting to the Chair of the Oversight Board as well as the Chief Executive for NHS GGC);
• Professor Angela Wallace (Nurse Director, NHS Forth Valley), who was appointed in February 2020 to work with and succeed Professor Bain as the Health Board's Interim Operational Director for IPC (also jointly reporting to the Chair of the Oversight Board as well as the Chief Executive for NHS GGC); and
• Professor Craig White, who was appointed by the Cabinet Secretary for Health and Sport in October 2019 to work with the families of the children and young people in the paediatric haemato-oncology service to address communication issues within NHS GGC.

5. Alongside the Oversight Board, the Cabinet Secretary for Health and Sport commissioned a Case Note Review in her statement to Parliament on 28 January 2020. Overseen by Professor Marion Bain and a panel of independent external experts led by Professor Mike Stevens (Emeritus Professor of Paediatric Oncology at the University of Bristol), the Case Note Review team has examined the individual case notes of those children and young people in the paediatric haemato-oncology service in the RHC and the QEUH from 2015 to 2019 who had a Gram-negative environmental pathogen bacteraemia (and selected other organisms, as identified in laboratory tests). Its terms of reference are presented in Annex B and it has contributed to the Oversight Board's final report. Its own final report is being published separately and alongside this Final Report.

6. The Oversight Board has already set out some of its findings and recommendations in its Interim Report, which was published in December 2020.^[2] The Interim Report specifically set out findings and recommendations:

• for infection prevention and control, a review of key processes/systems and the approach to improvement of IPC in NHS GGC; and
• for communication and engagement, a review of the way in which the Health Board communicated and engaged with affected patients.

The Final Report does not repeat these findings. Annex C sets out what has been covered by the Interim Report, and what is covered in the Final Report, and the Interim Report recommendations are set out again in the Summary.

7. The Final Report presents findings and recommendations in the remaining areas that have been examined. Following this introduction, the report consists of several sections:

• Background to the Oversight Board: the context for the establishment of the Oversight Board and the infection issues within the QEUH and the way the Oversight Board took forward its work;
• Infection prevention and control: a review of the responsiveness, joint working between IPC and other key staff, and senior leadership of IPC within the QEUH, and how the Health Board has learned from the experience of the infection incidents;
• Governance and risk management: a review of the governance and management of risk with respect to these infection issues;
• Technical review: a review of the Health Board's current water safety policy in the QEUH and its approach to infrastructure maintenance given the infection issues faced by the hospital;
• Communication and engagement: a review of the Health Board's approach to the organisational duty of candour, its Significant Adverse Events Review policy and approach to Mortality/Morbidity Reviews;
• Case Note Review: a summary of the Case Note Review's independent Expert Panel's key findings as they relate to the Oversight Board's programme of work; and
• Conclusions and the way forward: the findings and recommendations of this Final Report, including an overarching assessment of NHS GGC's current escalation to Stage 4.

8. In addition, there are several annexes:

A. the terms of reference for the Oversight Board and its Subgroups;

B. the terms of reference for the Case Note Review;

C. a description of what is covered in the Interim and the Final Reports;

D. the Key Success Indicators identified by the Oversight Board;

E. the current structure of IPC governance and assurance in NHS GGC; and

F. a timeline of infection incidents in the QEUH between 2015 and 2019.