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

2. Background to the Oversight Board

2.1 Context for Escalation

9. On 22 November 2019, the decision was taken by Malcolm Wright, Director-General of Health and Social Care in the Scottish Government and Chief Executive to NHS Scotland, to escalate NHS GGC to Stage 4 of the NHS Scotland Board Performance Escalation Framework. An Oversight Board was established to focus on three broad areas:

• infection, prevention and control;
• governance; and
• communication and engagement.

10. Escalation of NHS GGC to Stage 4 was set within the procedure for NHS Board performance. The Escalation Framework lays out the triggers and actions when Health Boards are unable or hindered in taking forward their essential responsibilities. The Framework describes a scale of acuteness for taking action, and what steps are needed following a decision to escalation, depending on the 'stage' on the framework. Stage 5 is the most serious stage; Stage 4 is defined as "significant risks to delivery, quality, financial performance or safety, (and) senior level external transformational support (is) required." It is applied where the Scottish Government believes that a NHS Board requires enhancement to address local issues and additional direct management or transformation support may be required.

11. Escalation came against a background of a series of infection issues affecting children and young people in the paediatric haemato-oncology service at the QEUH and the RHC over a number of years, combined with rising concerns about the source(s) of those infections and how they were being handled.

• While cases were reported in 2016 and 2017, concerns significantly mounted between January and September 2018 when the number and diversity of type of infections substantially increased. According to Health Protection Scotland (HPS), there were at least 23 cases, involving 11 different organisms.
• From Spring 2018, there was a succession of outbreaks, including one in September in the RHC which led to the de-canting of patients into the QEUH and extensive (and continuing) refurbishment of Wards 2A and 2B. In 2019, there was a further major outbreak in Ward 6A in the QEUH, into where the children and young people had been moved after de-canting.
• The organisms associated with these outbreaks were unusual and often linked to environmental bacteria. In 2018, water testing results suggested that there was systemic water contamination in the QEUH, prompting the introduction of a site-wide chemical dosing solution later that year.
• Concerns had been raised about the fitness of the new hospitals by several clinicians and microbiologists with respect to environmental infections at various points over the period, dating back to the completion and handover of the building. Some QEUH/RHC clinicians and microbiologists did not feel that their concerns – particularly about water and ventilation safety – were being effectively addressed, and in some cases, formal whistleblowing procedures were triggered.
• Concerns were also raised by families of the patients involved about how the Health Board was communicating and engaging with them in light of their increasing anxieties about the safety of the hospitals. (These issues have been discussed in the Oversight Board's Interim Report.)
• It was not until summer 2018 that senior management were made aware of the existence of external reports highlighting the risks of water contamination as early as 2015, but which had not been acted upon at the time. These reports were discussed publicly for the first time in November 2019.

12. In February 2020, NHS GGC was escalated again to Stage 4 for a range of issues beyond the circumstances of the QEUH incidents, including wider performance management on waiting times, the Board's out-of-hours service and financial matters. Work on this has been overseen by a separate Performance Oversight Group, chaired by John Connaghan, then-Interim Chief Executive of NHS Scotland. Care has been taken throughout not to duplicate areas being covered more thoroughly by this group.

13. The purpose of the NHS GGC/QEUH Oversight Board has been to ensure NHS GGC takes the necessary actions to deliver and increase public confidence in safe, accessible, high-quality, person-centred care at the QEUH and RHC, and to advise the Chief Executive of NHS Scotland that such steps have been taken – or as set out in the Cabinet Secretary's statement, to "[restore] confidence that the places families take their children to be cared for are as safe as they possibly can be." In particular, the Oversight Board has sought to:

• i. ensure appropriate governance is in place in relation to infection prevention, management and control;
• ii. strengthen practice to mitigate avoidable harms, particularly with respect to infection prevention, management and control;
• iii. build on and improve how families with children being cared for or monitored by the haemato-oncology service have received relevant information and been engaged with;
• iv. confirm that relevant environments at the QEUH and RHC are and continue to be safe;
• v. oversee and consider recommendations for action further to the review of relevant cases, including cases of infection;
• vi. provide oversight on connected issues that emerge;
• vii. consider the lessons learned that could be shared across NHS Scotland; and
• viii. provide advice to the Chief Executive of NHS Scotland about potential de-escalation of the NHS GGC Board from Stage 4.

14. Throughout this work of robust scrutiny and challenge, the Oversight Board has been focused on improvement. While that requires an understanding of what has happened in the past and how processes operated at different points in the period since the opening of the QEUH and the RHC, this has been in the service of understanding what happened with these incidents to support patients and families and assessing the quality and efficacy of processes in place now. History has been important in reflecting the Health Board's own capacity for learning lessons, making any necessary improvements and tracking the implementation and adequacy over those changes going forward. The Oversight Board has consequently aimed to ensure that learning is captured, shared locally and nationally, and most importantly, acted upon. It has also sought to highlight the improvements that have already been put in place by the Health Board in advance of and throughout this process.

Context of Other Reviews

15. The Oversight Board has acted separately from the Independent Review. On 5 March 2019, Dr Andrew Fraser and Dr Brian Montgomery were appointed by the Cabinet Secretary for Health and Sport to lead an Independent Review with the aim of: "establish[ing] whether the design, build, commissioning and maintenance of the QEUH and the RHC has had an adverse impact on the risk of Healthcare Associated Infection and whether there is wider learning for NHS Scotland." The Independent Review's report was published on 15 June 2020. NHS GGC has welcomed the Independent Review, and the Scottish Government has committed to implement the relevant recommendations.^[3]

16. A fuller accounting of these issues will be the responsibility of the Hospitals Public Inquiry. The Oversight Board has been careful not to duplicate its prospective work, but has necessarily covered similar territory in some instances in order to get to address the key issues of Stage 4. The Inquiry is chaired by the Right Honourable Lord Brodie QC PC and its terms of reference have been published.^[4]

2.2 Priority Issues

17. The Oversight Board has focused on assurance of current systems. Consequently, for the key areas that it has examined – IPC, governance and communication and engagement – the Oversight Board set out what 'good should look like' through a set of key success indicators (described in Annex D). These principles have been applied in how the Board has considered its terms of reference, essentially through a set of overarching questions:

• i. To what extent can the source of the infections be linked to the environment and what is the current environmental risk?
• ii. Are IPC functions 'fit for purpose' in NHS GGC, not least in light of any environmental risks?
• iii. Is the governance and risk management structure in NHS GGC adequate to pick up and address infection risks?
• iv. Has communication and engagement by NHS GGC been sufficient in addressing the needs of the children, young people and families with a continuing relationship with the Health Board in the context of the infection incidents?

Major aspects of questions iii and iv were addressed in the Interim Report (as summarised in Annex C). The concluding chapter of the Final Report returns to these questions as a whole.

18. These issues have arisen in relation to a particular patient group within the QEUH, but the Oversight Board has widened its focus where wider implications have been important to acknowledge, whether for the whole Health Board or NHS Scotland.

19. The Oversight Board conducted its work through a review of key documents and direct inquiry with NHS GGC involving experts who took part in the Oversight Board and its Subgroups. Documentation included:

• the papers and material presented by NHS GGC to the Oversight Board's meetings, including minutes of the Health Board, relevant committees (such as the Board Infection Control Committee and the Clinical and Care Governance Committee) and Incident Management Teams (IMTs), action plans and special presentations;
• specially-commissioned topic-specific 'situation, background, assessment, recommendation' papers (SBARs) from NHS GGC as well as external experts and statements on specific issues, such as the use of anti-fungal prophylaxis, water testing policies and the approach to Significant Adverse Events Reviews;
• material provided previously to the Cabinet Secretary and the Health and Sport Committee of the Scottish Parliament by several NHS GGC clinicians and microbiologists; and
• key external documents, such as the Health Facilities Scotland (HFS) report, 'Water Management Issues Technical Review: NHS Greater Glasgow and Clyde – Queen Elizabeth University Hospital and Royal Hospital for Children' (finalised March 2019), and the HPS reports, 'Summary of Incident and Findings of the NHS Greater Glasgow and Clyde: Queen Elizabeth University Hospital/Royal Hospital for Children Water Contamination Incident and Recommendations for NHSScotland' (published February 2019) and 'Review of NHSGG&C Paediatric Haemato-oncology Data' (published November 2019).

20. There was no programme of comprehensive interviewing or evidence gathering from individuals and organisations, apart from what was undertaken as part of the commissioned work described above. However, specific clarifying discussions were held with representatives of the affected children, young people and families, some NHS GGC clinicians and microbiologists that had raised concerns about the Health Board and NHS GGC representatives throughout the Oversight Board's programme of work. The Oversight Board is grateful for the full support provided by all to this work.