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

3. Infection Prevention and Control

21. As noted in the Interim Report, the last few decades have witnessed an increased sensitivity to the risks associated with hospital-associated infections. The Vale of Leven Inquiry underlined the importance of rigorous processes, monitoring and escalation procedures in addressing the new challenges to IPC, and its recommendations^[5] have underpinned the current systems across NHS Scotland, and the requirements set out in the National Infection Prevention and Control Manual^[6].

22. New national guidance and expectations (especially through the National IPC Manual) form one part of the context to reviewing the approach to IPC in NHS GGC. The other is recognising the unprecedented challenges of the problems associated with the building of the QEUH: these have been rehearsed in the Independent Review's final report and are not repeated here. However, the shortcomings of the hospital environment formed a challenging set of difficulties for the Health Board as it experienced an unusual number and diversity of environment-related infections. While the National Manual now contains aide-mémoires^[7] addressing water- and ventilation-associated infections, national advice and support on these unusual infections was not consistently available through this period.

23. The background of an increasing need for ever-more robust IPC procedures and the drive for improvement form an important backdrop for the Oversight Board's assessment of IPC within NHS GGC. In its terms of reference, the Oversight Board recognised that there would be key points of learning and a need for improvement for NHS Scotland as a whole. Consequently, while it can be difficult at points to separate out historical and current matters, the Oversight Board has concentrated on issues and incidents and considered this in relation to the current and future capability of IPC in the Health Board. The following chapter balances a review of how the Health Board reacted to the emerging infection challenges with an understanding of what it has learnt from those experiences and whether the current systems provide assurance that any future outbreaks would be managed in a satisfactory way.

24. The concept of assurance is at the heart of the Oversight Board's work. Specifically, the overarching question before the Oversight Board has been whether current IPC processes within NHS GGC have been 'fit for purpose', in terms of national standards and good practice. In this respect, the Oversight Board has measured the Health Board against the key success factor: "the current approaches that are in place to mitigate avoidable harms, with respect to infection prevention and control, are sufficient to deliver safe, effective and person-centred care" (as set out in Annex D). It has also emphasised assessment of whether NHS GGC has been able to recognise any shortcomings through the succession of incidents, taken appropriate steps to address them (and indeed, acknowledge them to relevant parties, such as patients and families) and sought to prevent them being repeated. These are essential features of an organisation which has the ability to learn from its experience and find better ways to deliver care and support patients and families.

25. To answer the overarching questions for this work – particularly, are IPC functions fit for purpose in NHS GGC, not least in light of any environmental risks? – the Oversight Board set in motion a range of work. In particular, the Oversight Board has:

• commissioned a detailed description of the timeline of infection incidents between 2015 and 2019 and formal meetings to address the incidents, to present a narrative of how the outbreaks seemed to emerge and acted upon (as set out in Annex F);
• commissioned a system-wide peer review of current IPC systems and processes and associated governance scheme of delegation and escalation mechanisms against relevant national standards and guidance through the IPC and Governance Subgroup;
• commissioned bespoke SBARs on particular issues, such as the use of prophylaxis drugs and the current water safety policy;
• received reports from key individuals placed within the Health Board, as noted above, particularly Professors Bain, Wallace and White; and
• determined if there were any gaps when mapped against national standards and guidance and, if so, identify areas for improvement and shared learning with respect to IPC audit, performance, compliance and assurance, as well as operational delivery of IPC, including staffing/resourcing, minimum skills and joint working between relevant units.

26. Several IPC issues have already been reviewed in the Interim Report, specifically certain systems and processes (such as compliance with the National Manual and the use of Healthcare Infection Incident Assessment Tools) as well as the approach to improvement in IPC. The Final Report addresses the remaining key issues for IPC:

• Responsiveness: over the period, how did IPC functions identify relevant contamination issues and respond to the outbreaks, particularly with respect to identifying infections early enough, taking appropriate action and learning from each incident through understanding the potential sources;
• Joint working in IPC: as was described in the Interim Report, the systems and processes that enable effective IPC within a Health Board depend not just on the effectiveness of the IPC Team, but how that Team links with other key functions across the organisation – this section reviews how well cooperative working to support IPC was evident in the QEUH, particularly between key staff with a responsibility for undertaking IPC such as Facilities and Estates and microbiologists;
• Leadership: the effectiveness of the current structure of responsibilities for the IPC Team in NHS GGC, and whether those divisions of responsibilities are best suited in these circumstances; and
• Learning from the Experience: the programme of work that NHS GGC has put in place to start addressing the issues arising from escalation, led by the Board Chief Executive.

3.1 Responsiveness

27. The responsiveness of a Health Board to infection incidents is critical to assurance on IPC. A responsive approach to IPC would be characterised by: clear descriptions of processes and systems within the governance system; the ability to identify and respond quickly, appropriately and effectively to incidents; ensuring the right processes remain in place (and adapted as appropriate in an improvement culture over time); having the right individuals and services working together; knowing when to stand down support; and having a robust approach to any 'lessons learned' in reference to best practice and national standards.

28. How the Health Board should respond to infection outbreaks was provisionally set out in the Governance and Quality Assurance and Accountability Framework for Infection Prevention and Control Services developed by NHS GGC (as described in more detail in the Governance section, which will focus on how escalation and risk management has taken place). The document was developed by NHS GGC in response to a Healthcare Improvement Scotland (HIS) inspection in January 2019.^[8] A requirement of this inspection (which was to be implemented immediately) was to improve governance in both estates and facilities and infection prevention and control teams to assure themselves of safe patient care in line with the Scottish Government's guidance Blueprint for Good Governance (2019). Plans for implementing this in NHS GGC have been progressing through the lifetime of this Oversight Board.

29. The document describes a process for the management of infection incidents/outbreaks, including the establishment of an IMT, reporting mechanisms to the Board Infection Control Committee and relevant Sector, Directorate and other Board Committees, including inclusion in the weekly Healthcare Infection Incident Assessment Tool (HIIAT) reports to HPS (formerly, but Antimicrobial Resistance and Healthcare Associated Infection (ARHAI) Scotland latterly). The Framework also aims to describe the formal delegation of authority and responsibilities within the Health Board.

30. To assess NHS GGC's responsiveness, several elements have been considered by the Oversight Board:

• its response to the 'phases' of incidents over the period, particularly in the context of whether appropriate action was taken at the earliest possible juncture;
• how precautionary (or prophylactic) antibiotic and anti-fungal treatment was prescribed to the patient group, apparently as part of the mitigation of potential infection risks, in response to the concerns that were raised by some families about the implications of their use and as part of an understanding of how the Health Board responded to the prolonged uncertainty regarding the infection incidents; and
• the learning derived from the incidents and the Health Board's responses.

Responding to the Incidents

31. Infection incidents in hospitals have regrettably been a regular occurrence across Scotland over the last few decades; indeed, internationally it is recognised as a key risk within the clinical setting. In seeking assurance that a Health Board is addressing incidents effectively and timeously, the issue is consequently about prevention as well as control. It is also important to consider whether a Health Board is acting in line with established good practice and national standards. In the case of the incidents at the QEUH, there are significant additional elements to consider.

• First, the number of Gram-negative and other environmental bacteria and the link to environmental risk presented challenges to the Health Board because of the diversity and rare occurrence of the organisms identified, and indeed, the absence of comprehensive national guidance on these matters at the key points in the timeline.
• Second, the succession of incidents over the period raised questions related to the environment of the building, as described in some detail in the Independent Review.

Consequently, it is important to recount the sequence of incidents (through the timeline of incidents found in Annex F).

32. Reviewing the period from 2016 to 2019, 2018 emerges as a critical point; before then, incidents of environmental-related infections seemed to be treated by the Health Board as isolated. In its report published in February 2019, HPS summarised the incidents in this 'earlier' period, but focused on incidents within specific locations in the QEUH: ie. "any child linked to wards 2A/B RHC with a blood stream infection caused by a gram negative bacillus that had been identified from organisms identified within the water system." A focus on infections in the specific RHC wards for paediatric haemato-oncology patients does not give a full picture of the number and diversity of Gram-negative environmental infections seen before 2018 in the QEUH (as the timeline in Annex F shows).

• In 2016, in both Ward 2A and the Paediatric Intensive Care Unit (PICU), there were four infection incidents, involving ten patients.
• In 2017, there were 14 incidents, involving at least 25 patients and what appears to be 26 organisms. Three patients who died had infections during the course of their treatment.

33. At this point, IMTs focused on actions that typically addressed the cleanliness of the immediate environment and possible transmission via individuals. For example, there was a succession of extensive environmental cleaning exercises (or 'deep cleans') of the affected locations, and in 2017, a review of the cleanliness of the environment in terms of compliance with national standards by the Lead Nurse for IPC, the Senior Charge Nurse and the Domestic Manager. Staff also acted quickly to determine what might be done to improve practice through work to reduce Central Line Associated Bloodstream Infections (CLABSI) rates. IMTs were diligent and focused in their responsiveness – for example, in response to an incident of infection cases in Ward 2A in the RHC that were given a 'Red' HIIAT, in June 2017, the following actions were taken:

• cleaning of rooms occupied by patients;
• typing of bacteria;
• review of the environment by the Lead Nurse for IPC, the Senior Charge Nurse and Domestic Manager, covering cleanliness of ward and equipment and compliance of staff with IPC processes;
• education work with families about infection control;
• review of line care;
• regular reporting, including the updating of the Healthcare Infection, Incident and Outbreak Reporting Template (HIIORT) (13 times between 26 July and 15 August);
• increasing water sampling in Ward 2A; and
• advice explicitly from HPS of any further action that could be taken.

34. The isolated nature of these incidents did not necessarily point to any wider links with the wider environment. For the Gram-negative and unusual environmental bacteria incidents in the Schiehallion Unit in 2017, a connection to a common source was not made as each bacteria had a unique strain. Water testing results were consistently proving negative: 151 water samples were tested between 7 March 2017 and 17 November 2017, and all were negative for Elizabethkingia, coliforms, Pseudomonas sp., Legionella and Stenotrophomonas maltophilia within the water system. Although water testing results cannot be definitive that there are not environmental issues, there was no clear evidence of a 'pattern'.

35. Nevertheless, concerns about the environment had been raised by some clinicians and microbiologists since before the handover of the hospital, some of whom were raising the possibility of water contamination. The Independent Review has already discussed the succession of problems associated with the building at handover and commissioning that were starting to appear through this period. A list of failures to meet buildings standards and environmental defects was recorded in a SBAR in October 2017 by a number of QEUH clinicians and microbiologists, which prompted action by senior management to address the problems.

36. There is evidence of a recognition of the unusualness of the number and diversity of infections. For example, in early March 2017, a Problem Assessment Group (PAG) was convened to discuss the seemingly high number of positive blood cultures in Ward 2A. This group agreed several actions including a retrospective look back at blood culture rates on the unit by the IPC Team, revealing a gradual upward trend over the six months prior. Links between problems with the building and some infections were already being actively explored in IMTs. For example, in investigating suspected cases of Aspergillus in Ward 2A in 2016 (and again, in 2017 with another Aspergillus case), condensation resulting from the leaking of chilled beams as a source of infection was being considered as a potential source in the IMT (although the hypothesis was discounted after investigation).

37. For the Oversight Board, this raises the question of whether the potential risks associated with the building – especially water contamination – which were identified and acted upon in 2018 should have triggered action earlier by the Health Board. As already noted, action was being taken to explore environmental hypotheses through IMTs, although it is not clear if consideration of environmental risks was taking place in the relevant governance committees. For example, meetings of the Board Infection Control Committee (in November 2017), the Acute Infection Control Committee (also in November) and the Clinical and Care Governance Committee (December) highlighted several incidents of infection, but did not seem to discuss the number of infections as a whole or the reports of building issues.

38. Moreover, information about the individual incidents and the concerns about the building were not brought together in a way that might raise these questions. As will be explored further, this partly arose from the structure of reporting/escalation within the Health Board, and in particular, relationships (at the time) between IPC and Facilities and Estates staff. Of particular relevance here is a water risk assessment prepared by an external water specialist consultant (DMA Canyon Ltd) in April 2015, which drew attention to significant risks associated with Legionella arising from a large number of building defects, problems with the water system as well as high total viable counts (TVCs). The report was not shared with relevant IPC staff and microbiologists, nor indeed was it acted upon at the time (the issue is examined in more detail in the Governance section of this report). Consequently, while there was increasing evidence of environmental infection risks associated with the QEUH, the Health Board's mechanisms for identifying and transmitting relevant information to the right staff did not support staff considering in full any potential link between the infections and the emerging problems with the building.

39. The key period for infection issues was 2018, when a succession of incidents ultimately prompted more challenging questions to (and indeed, by) the Health Board in how to respond. This was the point where the evidence pointing to a more significant set of environmental risks proliferated. Throughout 2018, there was an increase in the number of infection incidents involving unusual organisms. As the February 2019 HPS report noted: "between the period of 29^th January and 26^th September 2018, 23 cases of blood stream infections (11 different organisms) with organisms potentially linked to water contamination were identified."

40. The cases occurred at different points across the year. After a series of infection cases in March 2018, IMTs were held until no new cases were reported and control measures were in place, at which point the IMT was closed (27 March). Following seven new cases of Gram-negative bacteraemia in Wards 2A and 2B in April and May, a further IMT was held, which was closed on 21 June, again when no further cases were reported. The IMT was reconvened in September when three new Gram-negative cases were identified in Ward 2A, and IMT meetings continued to be held through to the end of November, a period that included the decisions to de-cant the affected wards and to put in place a chlorine dioxide dosing system.

41. Despite the 'stop-start' nature of these outbreaks, the actions in themselves in this period were timely, robust and focused, although there were issues regarding their monitoring and follow up (as discussed in the Case Note Review chapter). The full Incident Management Report in April noted the actions that were taken in the first infection outbreak. In terms of investigation, these included:

• "patient timelines;
• retrospective analysis of bacteraemias;
• ongoing analysis with HPS support looking at current cases, retrospective cases and national picture;
• review of epidemiology from Public Health Consultant; and
• sampling of water, taps, showers, drains."

A range of control measures were deployed as well, including:

• "dosing of system with Sanosil and Chlorine;
• patient showers taken out of use for immunocompromised patients across RHC/QEUH site;
• extra hand hygiene precautions put in place, additional alcohol gel step;
• bottled water for drinking;
• bottled water to brush teeth;
• sterile water for [bone-marrow transplant] BMT patients;
• portable sinks to provide warm water for washing children on 2A and for parents use during periods of dosing;
• point-of-use filters fitted to hand wash basins and showers in all high-risk wards. A small number of filters were fitted in all other inpatient areas so that immunocompromised patients could be cared for in any ward if necessary. Some other day wards/departments had filters fitted depending on patient group. Quality assurance checks carried out at time of fitting by estates staff; and
• ciproxin prophylaxis for high-risk patient groups."

In addition, longer-term control measures were also identified and taken forward:

• "dosing with chlorine dioxide or copper-silver ionisation;
• removal of mixer taps in high-risk areas and replacement with more simple taps; and
• regular maintenance of tap-flow straighteners in other areas; [and]
• use of filters long term in high-risk areas."

The April Incident Management Report noted that these measures appeared to have been successful with the cessation of new bacteria (at least at that stage).

42. The actions did not always result in the anticipated outcomes. There were several actions whose results did not fit analytical expectations, often in ways that were unprecedented, for example:

• the failure of 'shock doses' of silver hydrogen peroxide to bring about rapid reduction in bacteria, suggesting the issue was not simply a problem with outlets as originally hypothesised;
• the application of filters leading to new problems with the drains, as the filters reduced distance between the tap and drain, causing increased splashing and new opportunities for bacteria to develop; and
• extensive mould in the showers and bathrooms, a reflection that the gyprock was not as water resistant as had been stated in the original building plans.

43. Throughout this period, a variety of hypotheses were explored with regards to the source of infections.

• Discovery of Gram-negative organisms in tap outlets – alongside negative water testing results for the main water supply – originally favoured a hypothesis that the individual water outlets were the source of infection (potentially as a result of the design of the flow straighteners and their encouragement of the development of bio-film). On the back of this hypothesis, the IMT sanctioned appropriate action in the widespread replacement of taps and installation of point-of-use filters.
• By May 2018, as drain swabs revealed a range of Gram-negative organisms, the hypothesis that the interaction of the sinks and the new point-of-use filters (and the resulting 'splash' effect spreading bacteria around the sink areas) was the source was being actively explored – and as a result, metal waste pipes in Wards 2A and 2B were replaced with plastic ones, sink drains were removed and drains were decontaminated with hydrogen peroxide.

44. Increasingly, there was a recognition of potential contamination of the water system for the site. By the IMT meeting on 16 March 2018, water testing had expanded from Ward 2A where the original infections had been detected to include a number of other locations across the RHC and the QEUH. By 27 March, it was reported at the IMT that "RHC, therefore, has evidence of [a] widespread problem", and that "overall Gram-negative pathogens and fungal counts… have been found throughout the QEUH and RHC sites." In the April Incident Management Report, it was concluded that:

"Water testing revealed contamination of water supply within RHC and QEUH… Hypothesis is that contamination took place during installation and has built up in the system creating thick biofilm."

The Incident Management Report further noted that the likelihood of a similar event occurring again was "high, in a new build hospital." This was reflected in the reports to relevant oversight groups, for example, the Board Infection Control Committee which heard on 28 March that "the issue is now widespread and they have positive results for RHC Hospital and in Ward 4B, QEUH," as well as that "it is unusual to have this level of bacteria in a hospital water supply."

45. The implications of this conclusion led to the introduction of longer-term and more comprehensive control measures. On 27 March 2018, when the IMT was stood down, a new Technical Water Group was announced, "consisting of IPC [Team], Facilities, HPS and HFS [which] will look into the remit of filter replacement, introduction of new taps, introduction of chlorine dioxide dosing to the water system and drain cleaning." The Technical Water Group brought together microbiologists, facilities and other key staff and gave direct advice to the IMT.

46. By June, the Group had concluded that a more comprehensive solution was required to address the environmental risks, and prepared its recommendations on the use of system-wide chemical dosing for the Board. Indeed, these longer-term measures became the focus for control and prevention going forward in the latter half of 2018, when it became clear that the key action to be taken by the Health Board to address the long-term safety of the water supply was chemical dosing.

47. The Technical Water Group was active and thorough in its planning for implementation of the system and in ensuring that water testing could provide verification of the expected results of water dosing. The planning led to the rapid installation of the system throughout the site by early 2019. Although it was expected to take a longer period for the full benefit of chemical dosing to be reflected in the incidence of infections, water testing results in the early months of 2019 seemed to suggest it was having some impact. Throughout the period, the Group was characterised by a clear focus, a sense of urgency and thought through the options and their execution, an example of how the Health Board was capable of an emphatic and effective approach to addressing the issues in the infection incidents. The Technical Water Group was an exemplary approach to recognising and acting upon the longer-term needs of infection control, and the model and experience merits national learning. The decision to introduce chemical dosing shows that the Health Board could take major decisions to support the health and safety of patients.

48. The Health Board was also active in 2018 in drawing in external advice. In March 2018, HPS and HFS were formally called in to review the range of incidents as a whole, triggered by the Scottish Government invoking the National Support Framework. Independently, NHS GGC sought out other Health Boards in Scotland as well as Public Health in England to see if there were any similar experiences of such incidents. Other hospitals, such as Great Ormond Street, were also visited to understand their practices in relation to water and ventilation systems. While such advice did not always provide NHS GGC with a decisive set of answers or solutions to its unique challenges, it demonstrated that the Health Board recognised the limits of its ability to understand and act on these incidents and the need to turn to appropriate expert advice from outside.

49. The role of external support is important to draw out. Although the Health Board had clear responsibilities for action here, it did so within a wider national framework of reporting and advice. Infections incidents were systematically reported to HPS (and latterly, ARHAI Scotland) throughout the period. As has been seen, HPS and HFS were invited to examine the issues from their perspectives. In March 2018, HPS had informed the Scottish Government of its findings of systemic water contamination, and later that month, the Chief Nursing Officer invoked the National Support Framework (escalation process). From this point on, there was regular – and at times, intensive engagement – nationally on these issues. While the Health Board clearly led on these issues, for this period up until escalation to Stage 4 in November 2019, there was broad agreement on the nature and timing of the actions that the Health Board was putting forward and alternative courses of action were not being recommended from outside.

50. Nevertheless, the recurrence of infection suggested that all of these actions may not have been sufficient. Frustration was particularly expressed by clinicians. Early in 2018, exasperation was evident among some clinicians that concerns about the building and environment had been raised before, but not addressed (as noted in an October 2017 SBAR, described in detail later). On 6 March 2018, some felt that, while concerns had been reported "to the highest level in GGC and HPS over two years ago", they "felt dissatisfied that there had been any response from senior management or outwith GGC which offered reassurance to clinicians." At 8 June IMT, it was reported that "[clinicians were] saying they are not confident [the IPC Team] are in control of the environment as there have been numerous issues surrounding Ward 2A since its opening" (though they were met after the meeting and were reassured by the steps being taken by the IMT). This persisted into 2019 – for example, at an IMT in August, it was noted that:

"[Clinicians] feel that it has been over a year since this has been highlighted and the problem still exists even after moving into Ward 6A, QEUH. Clinicians think the control measures are not working and it is still unclear what the underlying problem results in these Gram-negative bacteria."

As the infection incidents continued, it created an increasingly difficult environment for IPC action to be taken emphatically and in a way that would command widespread confidence.

51. Ultimately, in September 2018, the proliferation of cases and the need to work on the affected wards led to the decision to de-cant the patients of Wards 2A and 2B in the RHC to Wards 4A and 6B in the QEUH. The background and handling of this de-cant has been discussed in the Oversight Board's Interim Report, but the action is notable in the context of IPC for several reasons.

• First, it demonstrated the importance of patient safety that the Health Board continued to prioritise through these incidents – taking the decision to de-cant would have been a difficult one, and its implementation required significant planning and communication with the children, young people and families.
• Second, such a major step could be seen as an admission that other IPC measures were not working sufficiently to address the issues, and that the last recourse for the Health Board was to remove the patients from the immediate environment. This was envisaged as a short-term move but has since become a prolonged removal because of the succession of building problems uncovered in Wards 2A and 2B. This has had the risk of strengthening the perception that the Health Board is unable to address the infection problems.

52. In 2019, a number of cases arose that re-ignited environmental concerns about the QEUH. What was particularly striking about these cases was their appearance in new locations of the building (though with the same immuno-compromised patient group), including Ward 6A in the QEUH and the PICU. These included:

• One paediatric case of Cryptococcus neoformans in January (as well as one adult case). Potential links to the environment were debated by the microbiologists, although the Independent Review and an internal Health Board report concluded that this hypothesis was highly unlikely. (As the Independent Review covered this issue, the Oversight Board did not review this in detail.)
• A series of infections in Ward 6A that started in June 2019, including incidents of Enterobacter cloacae, Mycobacteria chelonae, Chryseomonas, Stenotrophomonas spp. and Elizabethkinga miricola, with a particular spike between August and November.

53. By 2019, when the new incidents were appearing in Ward 6A , a range of alternative hypotheses were being explored as to the source of infection. Water testing results suggested that the chemical dosing was working, but environmental explanations were still being sought (and as has been seen, water testing results could be limited as a predictor of infection – the negative results in 2017 were followed by the extensive evidence of contamination in the 2018 outbreaks). For example, it was hypothesised that the leaking of chilled beams was giving rise to the growth of the bacteria, though ultimately this was concluded not to be a source. In August, the IMT was reporting:

"The hypothesis of Gram-negative environment bacteraemia is still unexplained. It is the nature of the Gram-negative environment organisms being found and not the number which is convincing. The group are happy with the water coming out of the taps. The only other source is the chilled beam."

However, by the end of the year, following further analysis, that hypothesis was no longer being actively explored. Throughout the 2019 set of incidents, IMT action seemed to concentrate on local explanations – such as the chilled beams and the 'smart hubs' located in the wards – and there was limited discussion of the implications of a potentially wider-ranging contamination of the water system.

54. The infections in Ward 6A led to the establishment of an IMT in June 2019, which largely continued through until November. The number and diversity of cases prompted significant discussions within the IMT on the source of the infections (which is considered in the following section), but it is important to note the range of actions taken in response, including:

• restricting admissions into Ward 6A from 2 August onwards, with new patients being diverted to other Health Boards;
• consideration of alternative accommodation;
• a dedicated action plan by Facilities and Estates to address the issue of chilled beams in Ward 6A;
• a Standard Operating Procedure (SOP) developed for obtaining regular water, environmental and chilled beams samples; and
• prescription of precautionary prophylaxis.

There was also a review of the triggers for IMTs and actions to be taken, which was agreed in November and included:

• Root Cause Analyses to be done on all cases going forward (a significant change in practice that it is surprising had not been more explicitly and widely considered earlier, given the succession of incidents);
• a procedure for PAGs to be set up where two Gram-negative bacteria cases are reported within 30 days, or the upper warning limits of Statistical Process Charts are met; and
• if an immediate source is not identified, external advice to be sought early on a more systematic basis.

However, when the IMT was formally closed that year, and the November 2019 HPS report echoed its February 2019 report on the lack of evidence of a single source of infections, efforts to further understand the sources of infection in the context of potentially widespread water contamination continued to be challenging.

55. Several points are striking about what took place in 2019. The context was a set of infection incidents showing a similar scale and diversity of environmental-related bacteria to what had occurred to the same patient group before the de-cant in the RHC. Sources of the infections were proving very difficult to identify, frustrating to both the clinicians working with the patient group (as already highlighted) and the microbiologists seeking to understand what was happening. The continuing uncertainty – and increasing media focus on what was happening – created a highly pressured climate for staff grappling with an elusive, complex problem. Despite this, the IMT was responsive to the immediate infection issues, not simply in terms of actions to address the environment of Ward 6A, but identification of alternative accommodation as well.

56. However, despite the consistent commitment of staff to determining the sources and providing the best care to the patients, what was notable about the IMTs during this period – and the staff working together on IPC and the consequences of the outbreaks – was an increasing lack of cohesion and disintegrating working relationships between some staff, which seemed to spill out over into the conduct of the IMT meetings. The lack of unity has been discussed at length in the Independent Review's report and will not be rehearsed here, but it presented an important backdrop to the actions being taken.

57. What remained – and could not be discounted – was the persistent possibility of a link to the building. While actions in response to individual incidents appeared robust and appropriate, there continued to be a lack of an explanation for the source of these infections. This is not unusual for infection incidents, and the Health Board cannot be faulted for the efforts put in place to try to understand what was happening. However, by 2019, it was becoming clear that the question of whether the infections should be more systematically considered as a whole rather than individually should have been pressing. This was the view taken by the Scottish Government in 2019 when it asked the Health Board to examine a number of incidents in the PICU together rather than separately; and indeed, the Health Board is currently pioneering new methodologies to consider how such a 'long view' can be developed for the benefit of NHS Scotland. In that context, what is equally important to the responsiveness of individual IMTs was how the Health Board as a whole was using risk management and escalation to address these environmental risks against this background of significant uncertainty; this is reviewed in the chapter on Governance.

Use of Precautionary Prophylaxis

58. The use of precautionary prophylaxis treatment has been a complementary approach to the IPC measures introduced to address the specific environment of infection locations and embedding good hygiene measures among staff. Their use has provided an additional protection to the children and young people against potential infections. However, there have been questions raised by some of the families about the approach to such prescription, not least around its prolonged and what appeared to be at times blanket use for the group of affected children and young people as a whole (as noted by the Cabinet Secretary in Parliament in December 2019^[9]). Additional medication for such a vulnerable patient group needs to be considered carefully on a case-by-case basis, and communicated in a way that is clear and open about the rationale for its provision and which complements existing messages about the safety of the environment. Reviewing the approach has been an important aspect of the Oversight Board's work.

59. Prophylaxis treatment has been provided throughout the period of heightened awareness of infection risks. In October 2017, control measures included clinical teams risk assessing Ward 2A patients on a case-by-case basis on the prescription of anti-fungal prophylaxis. In response to infection incidents in March 2018, children and young people received Ciprofloxacin prophylaxis, while high-risk patients were provided with anti-fungal prophylaxis in January 2019 in the wake of the Cryptococcus cases. Its significant use was increasingly subject to clinician review towards the end of 2019. For example, in October, it was decided that patients in daycare should not be receiving it, a reflection of issues that were becoming more apparent in the widespread approach to their use.

60. The Oversight Board asked one of its members – Dr Andrew Murray, Medical Director of NHS Forth Valley and the co-chair of the Managed Clinical Network for Children's Cancer Services Scotland – to meet with a multi-disciplinary team of senior RHC clinicians for a clinician-led review of the use of these medicines in December 2019. The frontline team confirmed to Dr Murray that the use of antibiotic prophylaxis was being tailored to the needs of each individual patient and that families would be fully informed on their use and why. The haemato-oncologists confirmed that they had been reassured by Infectious Diseases and Infection Control specialists in the Health Board that ciprofloxacin was no longer required as a precaution for every patient with a central venous catheter.

61. Implementing this change in practice immediately was challenging given the heterogeneity of the patients in terms of the stage of their illness and other clinical features, but the approach was clearly set out. Similarly, anti-fungal prescribing was based on clear criteria and required to be continued when clinicians determined that patients met those criteria. The guidelines for anti-fungal prescribing are being reviewed to ensure alignment with latest evidence.

62. Following the meeting, Dr Murray recommended that the haemato-oncology clinicians should meet regularly with Infectious Diseases and IPC colleagues to ensure that the prescribing of antibiotics and anti-fungals remained case-by-case, clinically appropriate and in keeping with agreed guidance, and to review any adverse events through their prescribing, either in their regular weekly departmental meetings or separate governance group. It was also agreed that families and patients should be informed:

• any prescribing of antibiotics such as ciprofloxacin would be because the consultant had risk-assessed that patient on an individual basis;
• there would be no policy to prescribe all patients precautionary antibiotics because of environmental safety concerns;
• anti-fungals would be prescribed for patients according to a new protocol to be introduced, irrespective of location or current concerns; and
• all prescribing would be reviewed as appropriate by an oversight group with all consultants, meeting regularly – the Oversight Board suggests that the Clinical and Care Governance Committee undertakes a short review to ensure that these actions have been taken and to designate an appropriate means by which it can continue to assure themselves that these processes are being fulfilled.

Summary

63. In summarising the responsiveness of IPC within the Health Board, the Oversight Board concludes that once outbreaks were identified, the actions were swift and effective. Throughout the period, there was significant evidence that IMTs were characterised by commitment and pace in responding to individual incidents, notable for the determination of staff to put in place remedial actions to support patients and identify the sources of the infections.

64. That responsiveness also extends to more significant actions, particularly in 2018. The establishment of the Technical Water Group showed the Health Board capable of taking innovative and bold steps, carrying through to the difficult and resource-intensive decisions to introduce a site-wide chemical dosing system and to de-cant patients from Wards 2A and 2B, ultimately allowing extensive work to be carried out to address the environmental issues discovered there.

65. As the infection issues continued, the involvement of national bodies – and the Scottish Government – became more prominent. The Health Board showed itself open to external advice and reported the incidents and the actions being taken to others. While the responsibility for action remained with the Health Board, those actions were not being challenged by others.

66. However, the Oversight Board concludes that the Health Board's responsiveness was limited by problems in how different sources of information were being brought together to examine an ever more complex problem. The failure to share the DMA Canyon reports compromised the ability of IMTs and the IPC Team to act because key information was not available. The concerns raised by some staff before the October 2017 SBAR did not lead to full consideration of the emerging problems with the building in the appropriate committees. Staffing tensions and problems in working relationships seemed to make it difficult for relevant information to come together and consensus decisions on action to be taken consistently.

67. This seemed to limit more active exploration of the implications of environmental risk and the ability to see potential links between the infection incidents. This issue will be returned to in the last section of this chapter, and the chapter on Governance.

3.2 Joint Working in Infection Prevention and Control

68. IPC is not a standalone function, and the IPC Team does not operate in isolation. As set out in NHS Health Department Letter (HDL) 2005(8)^[10], the Chief Executive has overall responsibility for ensuring that IPC is integrated with clinical governance and patient safety. Clear good practice about the importance of joint working is embedded in national standards, and seen in IPC when operated at its best in NHS GGC. For example, the Technical Water Group showed the importance of bringing together Facilities and Estates staff, technical experts, microbiologists and those leading IPC. That cooperative approach is essential for early detection of any problems and robust prevention measures, and was an important theme in both the recommendations of the Vale of Leven Inquiry and the key guidance letter, DL (2019) 23^[11], issued by the Chief Nursing Officer on mandatory Healthcare Associated Infection and Anti-microbial Resistance policy requirements for all NHS Scotland healthcare settings.

69. In carrying out its functions, the IPC Team, in particular, needs to establish close links with other functions within the Health Board. For example, one of the IPC Team responsibilities is to "participate in the planning and upgrading of hospital facilities", as set out in the Health Board's Governance and Quality Assurance Framework for IPC Services (as reviewed in more detail in the Governance chapter), and that requires a close set of relationships with Facilities and Estates. As the infection incidents arose, particularly from 2018 on, and the issue of a potential environmental source of the infections was increasingly in the spotlight, the strength and effectiveness of those links came under closer inspection.

70. Aspects of those relationships have been assessed elsewhere. They have already been discussed in connection with the design, construction and handover of the hospital in the Independent Review. The Independent Review concluded that: "[the] quality of infection control advice relating to vital systems and standards, specifically with respect to both the water and air ventilation systems, was not sufficient to underline the importance of quality design and high standards of building practice." Its report highlighted issues around the relationship between IPC and Facilities and Estates during the handover of the building, reflecting, in part, a lack of operational readiness in taking responsibility for the building and the significant number of defects that needed to be addressed initially.

71. The Oversight Board concluded that the links between Facilities and Estates and IPC staff were inconsistent over the years. This has been most clearly highlighted by the failure of Facilities and Estates staff to take timeous action on the 2015 and 2017 DMA Canyon reports on water testing, which identified serious infection risks, and communicating those risks to relevant IPC and microbiologist colleagues. In the period up to 2018 in particular, requests for water testing results by IMTs and their Chairs did not receive a consistently adequate response – indeed, there seemed to be a lack of systematic rigour in such requests, how they were recorded and how they were responded to. As the Independent Review also noted: "There was extensive and inconclusive correspondence between ICDs, with Estates and Facilities management, and general management of the hospital. Management and technical information was not forthcoming that was needed to inform ICDs' decision-making."

72. In large part, this seemed to be a consequence of the pressures placed on Facilities and Estates in the hospital's early years and the inadequacy of its existing structures to deal with those pressures fully. The pressures included an unexpected requirement to oversee extensive remedial work on the building at handover and continuing coordination of a significant number of sub-contractors, contributing to an overall sense of 'fire-fighting' within the Health Board. In addition, there were other notable weaknesses that contributed to the failure to address the report. There was no formal Authorised Person responsible for the water system within the Facilities and Estates team before 2018. While it was recognised that certain people had particular expertise or knowledge of an area, such as water, they were not formally assigned responsibility for looking after an area. This seemed to have been compounded by a high turnover of staff within Facilities and Estates at this time with what has been described as lack of systematic handovers. Again, to cite the Independent Review: "A lack of clarity over the roles and responsibilities within the Estates and Facilities team, combined with overwhelming workloads, due to defects, snagging and incomplete works, meant there was a missed opportunity to address the significant problems with the water system over a period of around two years, during which the risk remained 'high'."

73. Latterly, there have been significant improvements within Facilities and Estates that have resulted in improved coordination, in response to the failures identified through the DMA Canyon report incident. With the appointment of the new Director of Facilities and Estates in 2018 (and indeed, a new Chief Executive taking up post earlier), there has been significant reflection and improvement in Facilities and Estates. There has been evidence of structural and procedural changes that improved lines of accountability within the function and with other parts of the organisation, the effectiveness of these functions and its coordination with IPC. NHS GGC acknowledged these historical issues in discussions with the Oversight Board. The structure of the Facilities and Estates team has significantly changed and there is assignment of specific roles and responsibilities to ensure that issues (and reports) would not be overlooked in future. There has been a greater level of formal compliance introduced within the organisation, supported by the formal training and appointment of Approved Persons, not only for water, but for other systems as well. Electronic compliance dashboards have been created for senior and estates managers to allow instant visibility of the compliance level on a site/sector and at Board level for all AE Audits, Water Risk Assessments, sustainability issues as well as the action plans supporting these reports. SOPs have also been introduced to ensure consistency among the work performed by the various sector estates teams.

74. This was reflected in improved coordination in support of IPC. A good example of the integrated approach was the Technical Water Group, as already detailed. This was particularly evident in consideration of the hypotheses of water contamination, assessment of different options for mitigation and taking forward the chlorine dioxide dosing solution. Overall, the terms of reference and minutes of the Technical Water Group and relevant oversight groups (such as the Board Infection Control Committee) showed integration working actively.

75. Staffing issues among microbiologists and IPC staff also created challenges in responding to the infection incidents. Periodically, these issues surfaced, complicating the environment for taking clear and coherent action. For example, questions were raised about roles and responsibilities by some individual clinical staff in 2017. In a SBAR of October by several microbiologists, it was noted that "roles within the infection control team are unclear and appear to have changed… [and] there appears to be a lack of resources to investigate potential outbreaks/ increase in infection rates". The Health Board took action to respond to these issues with a targeted action plan. A number of clinicians and microbiologists raised whistleblowing procedures within the Health Board. Also, as already noted, it is clear that there were notable tensions between staff. The Independent Review has commented on this more extensively, and noted:

"The whistleblowing episode beginning in 2017, lack of resilience of management arrangements and instability of the lead IP&C Team's relationships set the scene for contested leadership into a particularly turbulent period, when the microbiologist community could not find the capability that would have enabled them, when it was important, to be able to agree to disagree respectfully. The IP&C team continued not to function as a leadership team."

76. The Oversight Board did not review these specific issues in depth, but staffing problems were a consistent thread through much of the period, compromising, at the very least, a cohesive and focused IPC response to a highly complex set of challenges. Recognising the importance of these issues, Professors Bain and Wallace undertook Organisational Development work in 2020 as a matter of priority to address their potentially harmful effects. This entailed in-depth discussions with staff within and working with the IPC Team in an environment that encouraged frank review and reflection. The work consisted of a five-stage programme:

• i. 'entry and contracting': facilitating a series of interventions to ensure that staff are working in a positive and improvement work environment with appropriate support and governance;
• ii. 'data collection and diagnosis': interviews with staff and stakeholders;
• iii. 'feedback and action proposal': assessment and sharing of key findings and development of action plan;
• iv. 'implementation': taking forward actions with appropriate points of review; and
• v. 'impact evaluation and recommendations': fixing of end points and drawing out and implementing recommendations.

The results of this work have been important in identifying issues for immediate action and setting the long-term challenges and goals of the strategic work for change under the 'Silver Command' work discussed in the last section of this chapter.

3.3 Leadership

77. Leadership in healthcare is critical, perhaps no more so than when a health organisation is forced to address crises, not least prolonged ones. The impact on staff morale, patient, family and public confidence, and the ability to respond and learn from challenging situations cannot be underestimated. NHS Scotland – through programmes such as the Scottish Government-sponsored Project Lift^[12] – has recognised the importance of this. Ultimately that will depend on the quality and performance of individuals, but equally, it is important that the right structure of leadership responsibilities is set out for individuals to fulfil the expectations of their roles. That structure needs to be clear and appropriate for the challenges of the role. The Oversight Board has considered how responsibilities for IPC have been organised within NHS GGC with a view to considering assurance for the approach. The focus is wholly on how relevant posts and management structures have been defined.

78. One aspect of their responsibilities – how senior leaders communicated and engaged with patients and families affected by the outbreaks – was treated at length in the Oversight Board's Interim Report. Issues more closely related to staff management – not least in the context of the whistleblowing issues noted in earlier sections – are not reviewed here, as they will be more properly covered by other processes such as the Scottish Hospitals Inquiry. This section concentrates on how the key roles with IPC responsibilities have been defined within the Health Board.

Senior Executive Role

79. The draft Governance and Quality Assurance Framework for the Health Board clearly sets out key senior roles within the Health Board. The document itself remains draft (to take account of further changes to be made as part of current reform work, as described below) – this and the wider issue of governance are discussed in more detail in the Governance chapter. Within the draft Framework, the most senior responsibility for IPC lies with the Board Medical Director, to whom the Chief Executive delegated the role of Executive Lead for IPC. In overseeing and providing assurance on behalf of the Chief Executive, the Medical Director:

• "is aware of their legal responsibilities to identify, assess and control risks of infection in the workplace;
• has appointed an Infection Control Manager as required by HDL (2001)10 and HDL (2005)8 with sufficient resources to undertake this role;
• is aware of factors within services deliverer/NHS Boards which promote low levels of HAIs [Healthcare Associated Infections] and ensures that appropriate action is taken;
• has designated the prevention and control of infection as a core part of their organisation's clinical governance and patient safety programmes;
• ensures that there is progress towards appropriate provision of isolation facilities within their healthcare facilities; and
• ensures that IPC Teams work with nursing, medical staff and bed managers to optimise bed use, assess the infection impact of bed management policies, and implement changes to local policy to minimise the risks of infection."

The designation of the Medical Director as the Executive Lead is unusual within NHS Scotland – typically that role tends to sit with the Nurse Director in individual Health Boards – but there is no national specification. As IPC is a cross-cutting issue within Boards, arguably there is no 'natural' place for such responsibility to sit. What matters – and what the Oversight Board has focused on – is whether the nature of the responsibility is adequately set out and whether the supporting structure of leadership within the Health Board is appropriate for that responsibility.

80. The Oversight Board recognised the need for a dedicated senior role to lead change in IPC and address the IPC issues that have been highlighted by the infection incidents. That prompted the designation of a new Healthcare Associated Infections (HAI) Executive lead role, and eventually, the role of the Interim Director of IPC. This interim role has reported directly to the NHS GGC Chief Executive and has been positioned with the Senior Executive Group (not least as part of the COVID-19 pandemic emergency footing structures). The Interim Director of IPC attends Board meetings to present the HAI Reporting Template (HAIRT). From the outset, the Interim Director has had the brief from both the Nurse Director and the Board Chief Executive to direct all aspects of IPC, with the freedom and authority to identify system learning and improvement to ensure safe care for patients and to support staff across NHS GGC.

81. This is clearly an interim role, which Professor Wallace is fulfilling as part of a time-limited period to embed the work of transforming IPC. The Oversight Board understands that the Health Board, following publication of the Final Report, will put in place strengthened and permanent arrangements for the leadership and oversight of IPC within the Board.

Senior IPC and Management Roles

82. There are two other key roles that the Oversight Board reviewed: the Infection Control Manager; and the Lead Infection Control Doctor.

83. The draft Governance and Quality Assurance Framework described the responsibilities of the Infection Control Manager as follows:

• "coordinate IPC throughout the Board area;
• deliver the Board approved Infection Control Programme in conjunction with the Board Infection Control Committee and Senior IPC [Team];
• provide clear mechanisms for access to specialist infection control advice and support, including primary care (eg. general medical practitioners);
• assess the impact of all existing and new policies and plans on HAI, and make recommendations for change;
• challenge non-compliance with local and national protocols and guidance relating to prevention and control of infection, decontamination, antimicrobial prescribing and cleaning;
• report directly to the Director of Diagnostics;
• be an integral member of the organisations clinical governance structures; and
• produce the bi-monthly Healthcare Associated Infection Reporting Template (HAIRT) report for the NHS Board."

84. The Oversight Board endorses the description of the role, but would recommend that the role does not report to the Director of Diagnostics. Rather the relevant HDLs should be implemented to ensure clear and effective lines of reporting and accountability.

85. The Framework does not set out a description of the Lead Infection Control Doctor role – the Oversight Board recommends this role, and indeed, the role of Infection Control Doctors (ICDs) more generally, are clearly set out to present a complete picture of the key roles. The ICD role is much more complex than a label of 'ICD' – for a Health Board of NHS GGC's size, there should be numerous infection specialist roles covering ventilation, water, decontamination and surveillance and acute infection control (analogous with the Authorised Persons roles within Facilities and Estates).

86. At the same time, all microbiologists should have 'IPC' in their job plan given the potential urgent need for microbiologists to chair PAGs/IMTs at short notice. Similarly, work should be taken forward to ensure specialisation in the ICD role so that there is appropriate expertise in key microbiological issues – such as water and air ventilation – particularly for a Health Board of the size and complexity of NHS GGC. There is an imperative for national work to define these roles and expertise that should be taken forward by ARHAI Scotland.

87. The structure of IPC leadership was fluid throughout the period. For a prolonged period, several key leadership roles within IPC were being filled on an interim, rather than a permanent basis. While this may clearly address interim staffing issues, it may be indicative of difficulties in long-term recruitment to these posts and underlines a lack of stability about the roles. Similarly, the role of Lead ICD changed at several points over the period, and not always in a clearly planned manner: the illness of the incumbent led to temporary measures being put in place in the second half of 2017 was an examples of a point that would have presented challenges to clarity and continuity in IPC leadership when they were most needed. The issues were highlighted by the Independent Review, which noted that: "the resilience of IP&C leadership eroded, and it was not capable of addressing adequately the series of further adverse events that then arose".

88. The Oversight Board recommends that interim arrangements for these senior roles should be resolved and permanent incumbents decided as soon as practicable. However, since escalation, significant work is already being put in place to support changing staffing roles and structures as part of the Silver Command workstream (as discussed in more detail below). This includes giving two of the ICD roles additional sessions to enable creation of a Deputy Lead ICD and an ICD with dedicated responsibility for the built environment. The Oversight Board endorses these actions.

3.4 Learning from the Experience

89. With such a prolonged series of incidents, expectations are that the Health Board would learn from the experience, developing new ways of addressing the issues that were arising and ensuring the 'lessons learned' reflection was systematically undertaken. Certainly, evidence of learning is apparent across the period. There is a notable commitment to codifying learning in SOPs that captured new issues and required changes to processes arising from the infection incidents, such as the list of new infection organisms to be part of regular surveillance and the range of SOPs in 2018 introduced to address specific issues in Facilities and Estates (for example, ventilation to ensure consistency in compliance). The development of a single governance and assurance framework for IPC and the review of water safety policy are treated in later sections, but should be highlighted as NHS GGC's response to address the requirement of the HIS report.

90. A good example is the work of the Facilities and Estates compliance team, which created an electronic compliance dashboard for senior managers and estates managers to allow instant visibility of the compliance level on a site/sector and Board level for all AE Audits, Water Risk Assessments, sustainability issues along with all action plans supporting these reports. Evidence to support completed actions would also be held. The work was completed in early 2020 and means that all compliance-related documents and action plans are now in a single place, allowing tracking and follow up on action plans. Other evidence of responding to the challenges of these infections can be found in the introduction of the Infection Control and Built Environment Group and the Clinical Review Group in 2019 (the latter brings together infection issues with clinical issues and estates and formally reports to the management team).

91. However, the evidence of explicit and systematic reflection has not been apparent across the period. While there were occasional 'hot debriefs' (retrospective reviews of incidents with an emphasis on the lessons learned) – notably in May 2018 after the first 'wave' of infection incidents association with the 'water incident' – they were not regular. There was little structured review of past incidents and handling within the Health Board. IMTs did not 'call back' to previous incidents and actions taken, even though by the second half of 2018, the risk of systemic water contamination was being regarded as sufficiently high enough to lead to the site-wide chemical dosing solution. It is somewhat surprising that this was not more visibly considered by IMTs in the second half of 2019.

92. Similarly, there was no comprehensive review of the infection risks to the whole site from systemic water contamination. While there was some consideration of risks to other vulnerable patient groups – for example, by the Technical Water Group to guide the installation of point-of-use filters – there was no comprehensive review of the implications of this risk for the whole hospital. This is considered in more detail in the Governance section, but it meant that there may have been missed opportunities for full learning from these incidents. This seemed notably different from the approach taken to review the issues around the construction of the building, where the Chief Executive commissioned a comprehensive review of the building's defects, the hospital's capacity and flow, and the clinical outcomes for patients, which was presented to the Board at its meeting in December 2019.

93. Nevertheless, more recently there has been recognition of the need for a full-scale approach to reviewing IPC processes and structures. The recent work – put in place by Professor Angela Wallace – has been an encouraging step. Recently, the Health Board has launched a 'Gold Command' programme of work to address the different issues that gave rise to escalation to Stage 4 in the NHS Scotland Performance Framework. The 'Better Every Day' programme is chaired by the Chief Executive, and consists of four key strands of work:

• 'Better Performance', which addresses acute services performance, amongst other issues;
• 'Better Care and Experience', which covers the Quality Strategy's aims;
• 'Better Together', which aims to improve communication and engagement (and address issues discussed in the Oversight Board's Interim Report); and
• 'Better Safe, Clean and Clinical Environment' (under the banner of 'Infection Control is everybody's business'), in which improvements to IPC will be taken forward.

94. The latter 'Silver Command' workstream is jointly chaired by Professor Angela Wallace, the Director of Facilities and Estates and the Chief Operating Officer. It has several key elements with the following aims:

• Better Built Environment: "[to ensure] our Estate will support and enable safe, effective clinical care, irrespective of the care setting";
• IPC [Team]: "to provide expert IPC consultancy in order to deliver Quality – safe, effective, person-centred care to every person every time, and through a business partnering model that provides data, educates and supports the service to exceed the required standards";
• Microbiology: "to provide excellence in prevention, diagnosis and management of infection for every patient, every time"; and
• 'Everybody's business': "to ensure a Better, Safe, Clean Clinical Environment – a built environment to support and enable clinical excellence".

A work programme – rooted in the Organisational Development work discussed above – is being developed, and its key features are summarised below:

• IPC Team transformation and renewal work, including: internal 'best in class' benchmarking with stretch goals; redesign and reaffirming of IPC systems and processes; repositioning of the IPC Team as part of systems, roles and responsibility review work; and a transformation delivery plan informed by the above work incorporating external review recommendations;
• whole-system IPC improvement programme, including: a Board-wide IPC improvement collaborative; building capacity and capability in improvement skills; and the Organisational Development programme in support; and
• redefining system IPC roles and responsibilities, including: clarity on roles, responsibilities across the system in relation to IPC Team performance and delivery.

95. Detailed workplans and success measures are being put in place for this work by early 2021, and to date, key changes can already be seen.

• The new Whole Systems Infection Control Improvement collaborative is starting to focus on how to build improvement capacity within IPC, and will contain a workstream for the RHC.
• The North and South IPC Teams are developing a single-team approach to support shared learning and improvement.
• A weekly multi-disciplinary overview meeting on IPC is held to provide a form for early warning on issues and discussion of key reviews.

96. The Oversight Board commends this work, and suggests that the recommendations in its Interim and Final Reports are used to shape it going forward. This also applies to the Case Note Review, whose Overview Report also contains a number of key recommendations on the operation of IPC (some of which are noted in a later chapter). The Oversight Board also strongly suggests that success measures are set out and visibly used to track improvements as a way to strengthen assurance, not least with patients, family and the wider public.

97. There has also been discussion of how the experience of the Health Board can be used nationally to support NHS Scotland (and more specifically, NHS Assure), though the pandemic has delayed some of this work going forward. The Oversight Board welcomes this suggestion and urges it is taken forward when circumstances allow.

98. While the Oversight Board was primarily focused on the escalation of a single Health Board to Stage 4, the issues that led to escalation were not exclusively local. From a national perspective, the experience of NHS GGC provided two clear national 'lessons' for the Oversight Board. The first was the importance of ensuring the Health Board's experience of understanding and responding to potential environmental infections should be also used for national benefit. As the Scottish Hospitals Inquiry is committed to investigate in greater detail, the design and construction issues that have been linked to the potential for environmental infection may not have been unique to NHS GGC, and indeed, may continue to be a source of risk in health infrastructure policy in future.

99. Second, the experience highlighted a national gap in the understanding of how such unusual environmental-related infections can develop in hospital settings. NHS GGC's own research work will be of value here. The Oversight Board also determined there is a need for systematic national review of the limits of understanding and a research programme to address the gaps in IPC knowledge and practice.

100. At the same time, it is clear that NHS GGC did not receive sufficient external support to address these unusual challenges. Support was readily provided when requested but the provision of effective expert advice (and indeed, sustained challenge to what the Health Board was doing, or not doing) was not consistently forthcoming. The Health Board has noted that there was little national guidance for some of the issues relating to the infections, and there was tacit endorsement of the actions it did take. This reflects the lack of a strong set of dedicated institutions to provide that kind of specialist expertise – and where necessary, oversight and challenge – in how NHS GGC handled these issues. Put simply, there does not appear to have been a national organisation or process which could have pro-actively supported and assured NHS GGC in its IPC handling when these issues were becoming acute. The need for a strong national presence in this space will be returned to in the Final Report's last chapter.

101. The Oversight Board also noted that national recommendations in this area have been made in the past. The February 2019 HPS report noted key actions that should be taken forward nationally, including the following:

• HPS (supported by HFS) to undertake an urgent national water review of all healthcare premises built since 2013 to provide assurance that a similar incident has not and is not likely to occur elsewhere;
• HPS (supported by HFS) to establish a national expert group to review NHS Scotland current approach to water safety including as a minimum: review NHS Scotland current approach to water testing in healthcare settings, review NHS Scotland current surveillance and reporting of potentially linked water-related HAI cases, and based on findings develop risk based guidance on water testing protocols, results interpretation roles and responsibilities and remedial steps to be considered; and
• give consideration to the development of a best practice built environment manual which will be evidence based and cover, as a minimum, current and emerging evidence and the technical requirements from a clinical, patient safety and HAI perspective that will be adopted by all NHS Boards. This will include as a minimum: a review existing national and international guidance relating to water safety; development of robust requirements and guidance for all aspects of water safety; development of robust handover requirements in relation to water systems; review of the role of the IPC Team into the built environment, and produce clear guidance on roles and responsibilities; establishment of a risk-based approach to water testing and any remedial action required, including the roles and responsibilities that NHS Boards will adopt; review of the requirement for 100 percent en-suite single-side rooms and the number of clinical wash-hand basins per patient/bed; and review of the use of flow regulators across NHS Scotland and identify and associated risks and recommend any remedial actions required.

The Oversight Board understands that these recommendations are still being taken forward. They remain critical actions to be implemented, and are re-affirmed as national priorities in this Final Report.