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

8. Conclusions

219. The core of the Oversight Board's work has been the issue of assurance. Escalation arose from a history of complex issues that the Health Board had been experiencing since at least the opening of the QEUH, but the primary matter that gave rise to Stage 4 was a question of the 'fitness of purpose' of NHS GGC with respect to how IPC has been conducted in the QEUH, the way that governance has operated in relation to these infection incidents and the communication and engagement approach that has been placed under scrutiny by these events. Understanding the history of what has happened to the group of paediatric haemato-oncology patients and their families has been essential for the Oversight Board, but providing the full narrative and conclusions to be drawn on that history has properly been the prerogative of the Independent Review (and will be that of the Scottish Hospitals Inquiry). History is critical in ensuring that the right lessons are learnt. However, this Final Report has not sought to provide a complete account of what has happened, and by extension, an analysis of the individual and collective failures that have occurred.

220. In setting out this series of recommendations, the Oversight Board acknowledges that several are based on steps NHS GGC has already taken in recognition of these shortcomings. Throughout the period of the Oversight Board's work, significant improvements have been proceeding in parallel – indeed, some pre-date the decision to escalate, such as the substantial improvements that have been introduced in the operations and governance of Facilities and Estates, but clearly accelerated through the current Gold and Silver Command programmes. The Oversight Board has seen a clear commitment by the Health Board to start making the necessary improvements, a willingness that has underpinned the Health Board's engagement with this process.

221. In that spirit of cooperation, and on the basis that this is part of a wider trajectory of improvement for the Health Board, the Oversight Board believes the following changes are necessary to embed new improvements and accelerate improvement. This final chapter starts with the findings of the Oversight Board on the set of questions set out at the start of this report, then under each of the headings for the issues that led to escalation, a set of recommendations is described. Lastly, the next steps and way forward are set out.

8.1 Findings

222. In reviewing the material through the work of the Subgroups and the other commissioned work, the Oversight Board's investigation of the issues for escalation have crystallised around four key questions. As already noted, they link together, each contributing to a web of issues that have not always been easy to separate or understand the inter-linkages. The first question represents the fundamental challenge faced by the Health Board; the next three focus on how NHS GGC responded to this fundamental challenge, in line with the issues that gave rise to escalation.

• 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?

(i) To what extent can the source of the infections be linked to the environment and what is the current environmental risk?

223. This has become a key question over the last few years. It is clear to the Oversight Board that the infections have taken place against a background of systemic water contamination. As the HPS report in 2019 stated:

"Between the period of 29th January and 26th September 2018, 23 cases of blood stream infections (11 different organisms) with organisms potentially linked to water contamination were identified. As a result further testing of the water supply was undertaken across both hospital sites early in the investigation. This testing identified widespread contamination of the water system."

However, what is less clear is the extent to which these environmental issues can be linked with specific infections. As the Independent Review concluded:

"In the course of the Review, through examination of documentation, listening to witnesses, discussion with experts and input from the Review's expert advisers, and site visits, we have not established a sound evidential basis for asserting that avoidable deaths have resulted from failures in the design, build, commissioning or maintenance of the QEUH and RHC."

224. Pathways between water contamination and specific infection incidents have proven very difficult to establish by the Health Board itself, as the succession of hypotheses looking for sources of infection in the individual incidents has shown. However, in the absence of definitive sources, the strong possibility of a link has been – in the Oversight Board's view – undeniable. The Case Note Review concluded that a link was 'most likely' in 31 percent of the cases (ie. 'strongly probable', 'probable' and 'strongly possible' cases), noting that "by 2018, we suggest that simple observation should have identified a disturbing pattern characterised by the occurrence of bacteraemias caused by some very unusual microorganisms and apparent clusters of some of those more commonly encountered." In parallel, by 2018, there was significant evidence coming from clinicians and micro-biologists drawing attention to a succession of environmental defects within the hospital which could be typically linked with infection risks.

225. The question arises did the Board take the right actions at the right time in face of the balance of probability of water contamination. In reviewing this question, the Oversight Board acknowledges the exceptional challenges of the situation presented to the Health Board and the difficulties in establishing a clear picture of what was happening. The cases themselves did not necessarily suggest a pattern at first. Before 2018, water testing results did not provide evidence of water contamination (although the evidence of the DMA Canyon reports suggests that this evidence may be mixed). However, this is less a matter of numbers and whether infection rates were significantly different from other locations, but a reflection of the timing and sharp increase in infections, the diversity of organisms encountered, and the fact that a modern hospital should not be expected to see a sequence of infections like this.

226. A key moment of reflection was before the 'water incident' in 2018. Hindsight can only be partially helpful in this instance, but it is impossible not to speculate what action might have been taken, for example, had the DMA Canyon water report of 2015 (or indeed, 2017) been escalated to relevant staff and senior managers at an earlier stage. It is hard not conclude that this was a missed opportunity.

227. Through 2018 and beyond, it is clear that the Health Board accepted there was environmental risk by the actions it took in response, including the de-canting of Wards 2A and 2B, the introduction of chemical dosing, and in 2019, the temporary closure of Ward 6A. However, environmental risk has not featured more systematically and consistently in the consideration and actions across the Health Board. Much of the Health Board's response has been reactive – understandable in terms of immediate action to address individual incidents, but with a limited longer-term perspective and framework for action over the period as a whole. There is a strong record of IMTs focusing appropriately and effectively on specific incidents, often with a comprehensive set of measures to address the relevant issues, including cleaning regimes and programmes to replace parts of the water infrastructure. However, there has not been a comprehensive review of the potential risks across the hospital and all patient groups and how to address them across the period – one that considers the clinical, environmental, financial and public assurance risks of water contamination holistically and for the site as a whole. Applying the risk of water contamination in a consistently predictive and pro-active way was not evident. As the Case Note Review noted in its chapter in this report, there seems to have been a greater concern with process rather than risk and impact.

228. Strong remedial action has been taken by the Health Board. Given the water testing results, the chemical dosing system appears to have proven effective, Nevertheless, it is clear from the work of the Independent Review that there are significant problems associated with the building that will take time to unpick and fully rectify. The Oversight Board notes that there continue to be unusual environmental bacteria incidents at different points in the site. Whilst unusual environmental bacteria occur in all healthcare settings, the risk must continue to be monitored, evaluated, mitigated and reported. In light of this, ongoing vigilance is required with regards to effective control measures, good IPC, surveillance and risk escalation to maintain patient safety. The actions that the NHS Board has already taken, along with implementation of these recommendations, will ensure appropriate management of a safe and effective environment for patients.

229. The national dimension is highlighted by this question as well. While the Health Board had clear responsibilities and duties here, they turned for support and advice at different points to national bodies and the Scottish Government. The complexity of the issues faced by the Health Board was equally faced by these national bodies. Although the circumstances leading to the decision to escalate the Health Board reflected the specific problems and actions of NHS GGC, the incidents should be reviewed as a point of national rather than simply local Health Board concern. If there are shortcomings found by the Oversight Board now in how the Health Board was applying a strategic understanding to the implications of water contamination, they were not shortcomings highlighted nationally to the Health Board at the time. The Health Board has an acute need to learn from this, but the benefits of the learning will be for NHS Scotland as a whole.

230. The environmental risks associated with hospitals and infection control are increasingly better understood – not least through the efforts of NHS GGC in the course of these incidents – but there is more that could be done nationally, and arguably, should have been done before now, in terms of understanding the nature of those risks and developing and putting in place recognised good practice in how to address those risks. The Scottish Hospitals Inquiry will shed further light on these issues, but the Oversight Board believes that there is need for national action in advance of this. The recommendations below reflect on areas of national improvement and common, if not standard approaches, not least with respect to water testing and the collating and sharing of results.

(ii) Are IPC functions fit for purpose in NHS GGC, not least in light of any environmental risks?

231. The Oversight Board has already commented on aspects of IPC within NHS GGC in the Interim Report. That report noted that throughout the series of outbreaks, the Health Board was quick to react to individual incidents with clear IPC actions, and indeed showed capacity to learn and improve. For example, this was demonstrated by the establishment of the Technical Water Group in 2018 to provide a multi-disciplinary focus on the risks of water contamination and the options for addressing these across the site. IMTs were regularly held and responded systematically to trying to understand the source of infections and taking steps to mitigate the risks. Moreover, the willingness to take steps that were highly challenging, but justified by the risks to care and safety, was notable, not least in the decision to close Wards 2A and 2B in September 2018.

232. However, as the Interim Report detailed, these instances were not sufficiently consistent to provide full assurance. When examining a number of the key processes of IPC – such as the use of HAIRTs and the approaches to audit and surveillance – the Oversight Board concluded that there were necessary improvements to be made, and these were set out in the Interim Report recommendations. The Interim Report found that the IPC Team was still working in silos and not fulfilling its role as the service that embeds improvement and mainstreams good IPC across the Health Board. Moreover, work across different IMTs was hampered by the lack of systems for tracking actions and reviewing data.

233. Reviewing the history of how IPC in the QEUH responded to the incidents in detail, the Oversight Board would add a number of other findings.

• IPC's approach to the challenges was dominated by an incident-based, reactive approach. Imagination and determination were evident in how specific issues and incidents were addressed – especially in 2018 – but the ability to see and act on a wider perspective framed by the environmental risks and the infection incidents was not apparent. By 2019, the presumption of a water contamination risk should have been more explicitly considered. There also was no thorough and systematic consideration of the wider risks across the site of water contamination in terms of patient safety and environmental impact, or at least, it was not explicit. Apart from the introduction of the water dosing system – which the Oversight Board commends in terms of how this was put in place – a strategic approach to addressing these IPC risks was not evident.
• This reactive approach has been further hampered by the lack of systematic processes to examining infections and recording and following through key actions. The absence of data systems that bring together microbiological and environmental testing across the period suggests that the Health Board has not been in a position to examine these outbreaks as effectively as it should. As the November 2019 HPS report noted: "the microbiological and clinical data should be set in the environmental context including the environmental microbiology results such as water and ventilation sampling." The absence of continuing recording and monitoring of actions across different IMT meetings suggests that the Health Board has been taking short-term and reactive approaches to addressing the incidents (with the exception, as noted, of more exemplary decisions such as the introduction of chemical dosing). Moreover, as the review of HIIORTs in the Interim Report underlines, there are questions over whether the Health Board has been reviewing the risks associated with particular infection risks in a satisfactory way.
• As noted by the Case Note Review, there was little change in the thresholds for calling a PAG or proceeding to an IMT across the period. Given the recurrence of incidents, there should have been more active consideration of whether the standard definitions of an outbreak (as set out in the Health Board's own SOP) might need to alter to address a situation where unusual infections emerge in relatively small numbers.
• The Oversight Board received assurance on both the water safety/testing policy of the Health Board and its arrangements for addressing the building issues that have been exposed in recent years. Nevertheless, it notes the recommendations by the Case Note Review for improvements in how water testing and sampling are taken forward and the results used to support IPC.
• IPC requires active and strong relationships between a variety of staff and Health Board functions. These relationships were weak throughout much of this period. This was particularly mirrored in the poor links that have existed between IPC and key services, especially Facilities and Estates. The failure to act on the 2015 DMA report has already been discussed, and there were related issues with the provision of water testing results to IPC on a timeous and jointly cooperative basis. Moreover, some relationships between and among microbiologists and IPC were fraught within the QEUH and allowed to compromise effective working of services. It is clear that building better cooperation has been a priority within the Health Board through the recent Organisational Development work (and earlier, the changes introduced into Facilities and Estates), and the Oversight Board welcomes this focus on resolving these issues.
• The scale and intensity of the IPC issues facing NHS GGC strongly suggest the importance of adapting the leadership structure of IPC. The need for more dedicated roles to support IPC and a long-term solution to the Executive responsibilities for IPC has become increasingly clear through the continuation of these incidents. The Oversight Board welcomes the Health Board's recognition of this and the strengthening of leadership and management within IPC through the Silver Command work.

234. The Oversight Board recognises the significant work undertaken by the Health Board to address these issues. Once the Recommendations set out here (and in the Case Note Review) are being implemented, the Oversight Board will have the necessary assurance that the IPC issues that led to escalation will have been sufficiently addressed.

235. These findings also echo some of the findings in Lord Maclean's 2014 report from the Value of Leven Inquiry^[21]. Since it was published, NHS GGC has set out its implementation of that report's recommendations in full. The findings suggest a continuing need for the Health Board to be vigilant so that there is no recurrence of some of the problems identified by Lord Maclean. This seems to be particularly evident around the importance of strong, functioning IPC Teams, effective surveillance systems and robust channels for escalating and acting on key IPC issues. As already noted above, while the focus of any shortcomings are on NHS GGC, the implications of these issues must be recognised as national in scope, and demand national attention and action (as the recommendations will emphasise below).

(iii) Is the governance structure and risk management in NHS GGC adequate to pick up and address infection risks?

236. Leadership within a Health Board does not simply rely on the quality of key individuals, but how the organisation's governance systems are designed and operated in providing assurance and ensuring fidelity to organisational aims and decisions and NHS Scotland values. How that governance worked with respect to these incidents was a critical question for the Oversight Board. The reasons that gave rise to escalation were not sudden developments, and elements of them were arguably 'predictable' in light of the continuing problems with the QEUH given the prolonged problems and the increasing anxiety of the children, young people and families. It is legitimate to ask how senior levels of governance were made aware of the nature and scale of the problems over different points of the period and their responses.

237. As already noted, this leads to some overlap with the work of the Independent Review, and indeed, there is an artificial distinction to be applied to looking at the troubling history of the commissioning, design and handover of the building from an IPC perspective and how the incidents that arose thereafter were addressed. The events do not separate themselves neatly into distinctive bundles of issues, not least in terms of how the staff in the Health Board and the children, young people and families experienced them. But the Oversight Board has maintained a primary focus on responses to the infection incidents and understanding what took place, rather than how any shortcomings or issues with the building itself.

238. The Blueprint for Good Governance NHS Scotland has articulated the principles and practice of good governance in Health Boards. As the Blueprint sets out: "good governance is essential in addressing the challenges the public sector faces and providing high quality, safe, sustainable health and social care services depends on NHS Boards developing robust, accountable and transparent corporate governance systems." Amongst other responsibilities, good governance should identify current and future corporate, clinical, legislative, financial and reputational risks.

239. Against this test, there were significant failings in governance at key points. The receipt of the 2015 DMA Canyon report should have alerted NHS GGC at its most senior level to the fact that there were potential issues with the water system – but this report was 'lost' by Facilities and Estates at the time. Indeed, the DMA Canyon report of 2017 contained most of the same recommendations, suggesting that little or no action was taken with the 2015 report. Early and widely-broadcast warning of these issues would almost certainly have resulted in an accelerated focus and attention on what was going on (though it may not have avoided the same problems with identifying a source of infection in the incidents). This breakdown of responsibilities was a critical failure within the Health Board in the early stages of these incidents.

240. With respect to its role in assurance of the current systems, some of the issues that caused that breakdown have been addressed, particularly within Facilities and Estates. This has become part of the systematic review of IPC governance and procedures captured in the Gold Command work, and which are summarised in the governance and assurance description in Annex E. However, the Oversight Board is not yet assured that the wider weaknesses in governance this exposed have been fully addressed. The steps towards developing a clear description of IPC assurance and accountability have been welcomed, not least through the wider work on governance being led by the Chair. This should be accelerated with respect to IPC governance.

241. In many respects, the problems with governance can be presented as a series of breakdowns in parts of the Health Board (such as Facilities and Estates): in other words, the right channels for reporting and escalation were in place, but specific areas were not using them to draw sufficient attention to higher levels of governance. Nevertheless, while there was good evidence of assurance on the actions being taken, challenge was not apparent from minutes of meetings, and questions can be raised about whether the succession of incidents was sufficiently interrogated. Relevant committees and the Board were updated on developments, but the absence of more explicit direction and inquiry is not apparent from the record.

242. The review of escalation also underlines the difficulties of key IPC issues being raised by key IPC staff within IPC governance. The Oversight Board notes that some Health Boards facilitate the ability of Lead ICDs – for example – to raise particular concerns more easily and directly with relevant oversight committees. That approach might not be easily applied for a Health Board of the size and diversity of NHS GGC, but it is important that escalation processes are reviewed in light of the experience of the incidents.

243. These issues were further reflected in the absence of the infection incidents in risk management. The lack of full consideration of environmental risks is notable through this period. The approach to infection risk management needs to reviewed by NHS GGC, given the significant clinical, financial and ultimately, reputational damage that the infection incidents have caused. Governance cannot be expected to operate properly without the backbone of strong risk identification, analysis, recording and monitoring.

244. The incidents suggest the need to bring together the work of different parts of the governance structure for a more comprehensive overview, notably that covered by the Facilities Planning and Performance and the Clinical and Care Governance Committees. In a Health Board as large as NHS GGC, there is always a challenge of improving how cross-cutting issues can be addressed by the governance system as a whole. The work being put in place by the Health Board is a commendable step towards making the necessary changes. With good progress in implementing the relevant Recommendations below, the Oversight Board will have the necessary assurance that the issues giving rise to escalation will be addressed.

(iv) Has communication and engagement by NHS GGC been sufficient in addressing the needs of patients and families in the context of the infection incidents?

245. The Interim Report has already set out the Oversight Board findings with respect to communication and engagement issues. The Interim Report found the following.

• Within the paediatric haemato-oncology service, families were experiencing the prolonged impact of the potential problems in the clinical environment on their children, with significant disruption and uncertainty. Clear and regular communication and engagement was particularly vital.
• In that context, there was substantial evidence of a compassionate approach to communication by frontline staff. Transparency and sensitivity were regularly balanced in a way that families regarded positively.
• However, such an approach was found to be inconsistently applied across the Health Board. Too many patients and families felt that communication was not timely or fulsome, particularly from more 'corporate' services (as opposed to frontline staff); they felt they were too often the last to know and an impression deepened over the years of not being presented with a full and accurate picture of what was happening in relation to the incidents which has left a legacy of distrust among some families.

246. Another critical aspect of engagement is how the Health Board carried out its legal responsibilities to investigate and share information where deaths or serious failings have occurred. In this final report, the Oversight Board examined this with respect to the organisational duty of candour and the policies on SAERs and mortality/morbidity reviews.

• The organisational duty of candour was not activated for the infection incidents under review. The Health Board did not fully consider the legislative requirement to consider these cases in terms of how they could have resulted in harm, including actual or potential psychological harm. By this definition, a number of these incidents were within the scope of the organisational duty of candour. Concerns about competing organisational duties of confidentiality could have been addressed through more proactive engagement and involvement with the affected families and clinicians.
• However, with respect to the policy for SAERs and mortality/morbidity reviews, while noting areas for improvement, there are robust policies in place for these review processes within NHS GGC.

247. Through the Gold Command work, the Oversight Board understands that many of these issues are being addressed within the Health Board. Again, progress in taking forward the Recommendations here and in the Interim Report, the Oversight Board believes that the issues that gave rise to escalation will be addressed.

8.2 Recommendations

248. The recommendations of the Oversight Board are rooted in these findings. As already noted, the Interim Report has already set out recommendations on a number of issues – these have been included again in the Summary section at the start of this Final Report.

249. The recommendations note that there are important lessons for NHS Scotland as a whole as well as specifically for NHS GGC – indeed, the unusual experiences of the Health Board could provide important lessons for Scotland as a whole. The recommendations are based on what is required by the Health Board to provide assurance to justify de-escalation from Stage 4. In terms of the Key Success Indicators of the Oversight Board, set out in Annex D, they identify the changes that would be required to ensure that these success indicators can be met and assurance restored.

250. The recommendations are grouped according to each set of escalation issues – IPC, governance, and communication and engagement – as well as a more general group of recommendations at the end. National recommendations are set out below.

Infection Prevention and Control

251. Some recommendations for IPC have already been set out in the Interim Report. These are not repeated here.

252. The Final Report recommendations address the remaining IPC issues: the responsiveness of the Health Board's IPC to the infection incidents; the effectiveness of joint working in support of IPC in the QEUH; the strength and organisation of leadership in IPC; and the national dimension to improvement in these areas.

Recommendation 1: ARHAI Scotland should lead in developing and implementing a research programme to address any current gaps in the understanding of environmental infections and how hospitals can address them.

253. The lack of research and guidance that was available for the infection issues associated with the QEUH hindered NHS GGC's response. Much of its approach was necessarily reactive but given the lack of policy and guidance this should not have been wholly unexpected. Now that this experience has been gained, both the Scottish Government and the Health Board should consider how best this knowledge can be retained and utilised going forward – nationally, with respect to NHS Assure, the new national Centre of Expertise, and locally, in relation to how NHS GGC can respond better to any future such incidents – to ensure that investigation of any further incidents can be resolved much more quickly and effectively.

254. It is particularly clear that there are continuing gaps in the research and guidance available when it comes to managing an infection or outbreak suspected to be associated with the water supply. Further research needs to be undertaken to gain a detailed understanding of how unusual environmental bacteria can develop within a water system and how they can be transmitted from water systems to patients. Similarly, further work is needed on understanding how biofilm can grow, the time it takes, how it impacts on the growth of such bacteria and how such organisms mutate. It is important that future research takes account of the conditions in a sealed water system so that it is applicable to both new and existing hospitals.

255. The research should also take into account the occurrence of unusual environmental bacterial and fungal infections and outbreaks so that a baseline can be established on what should trigger consideration of 'unusual' levels of such infections, especially with respect to patients with suppressed immune systems.

256. Consequently, in collaboration with NHS GGC and other relevant bodies, ARHAI Scotland should set out a research programme identifying where the research and practice gaps are where further understanding is required and how such research can enhance the practical guidance available for Health Boards nationally. This should be set out by September 2021.

Recommendation 2: There are a number of existing national recommendations that were made in the 2018 Health Protection Scotland report that have yet to be fully implemented. ARHAI Scotland should provide an update and time-bound action plan for implementing these.

257. The national implications of what has happened at the QEUH have been raised at different points in the past, and indeed, clear recommendations have already been made historically (such as the Independent Review). These recommendations remain critical priorities for national action. The Oversight Board recognises that there has already been learning arising from the experience of the QEUH, but there is an urgency to ensuring that these lessons are mainstreamed across NHS Scotland as a whole.

258. The experience strengthens the existing recommendations for a national review of water infrastructure across the NHS Scotland estate, the establishment of a single, clearly-authorised national water review group and relevant changes to national guidance. An update and action plan (with clearly set and bound timescales) for implementing these recommendations, taking into account what has been set out in the Interim and Final Reports of the Oversight Board, should be provided to the Scottish Government by ARHAI Scotland by June 2021.

Recommendation 3: Strengthened arrangements for IPC, commensurate with the complexity and size of the Health Board, should be put in place in line with relevant national guidelines.

259. As part of strengthening the IPC arrangements within the Health Board, the Oversight Board recommends that consideration is given to securing a more dedicated Executive role for IPC. Such a role has emerged from the work of Professors Bain and Wallace, and the Oversight Board recognises the improvements that have taken place in IPC in NHS GGC as a result of their efforts. This role should have several overarching goals: it should provide a clear operational remit for IPC and dedicated senior-level oversight of emerging infection issues; it should be responsible for strategic forward planning, not least with respect to pursuing a continuing improvement agenda for NHS GGC, but also in ensuring the implementation of recommendations made by successive reports are embedded across the organisation; and the post-holder should be part of the Board and provide regular updates and lead Board-level consideration of infection issues and risks as appropriate.

260. It is recommended that the Health Board takes forward a long-term, permanent recruitment for this role as soon as practicable. It also recommends that particular attention is given the level of expertise and IPC knowledge required of candidates for this role.

261. An early priority for this role should be ensuring that the resourcing, expertise and structure of IPC – particularly with respect to the QEUH – is sufficient (within the context of the existing Silver Command work), and that the recommendations set out here are taken forward as quickly as possible.

Recommendation 4: The structure of IPC should reflect the continuing need to address the complex and continuing issues within the QEUH. IPC resourcing and skills should be reviewed, and active consideration given to whether there should be appointment of specific IPC roles with QEUH responsibility.

262. The expertise and resourcing of the IPC Team at the QEUH should be reviewed as part of the Silver Command work currently underway. Interim roles should be filled permanently as soon and as appropriately as possible. Potential new roles to support capacity should include consideration of additional capacity to support any further work that might be required, such as driving the key improvement programmes and work being set out as part of Silver Command action plans (and not least with respect to the recommendations presented here).

263. The skills and knowledge required to deal with the complex issues facing the Health Board such as water and ventilation expertise should also be developed within the current workforce where absent. Workforce planning for IPC – particularly in the QEUH – should ensure that there is sufficient expertise and specialisation in key areas (such as water and ventilation) and ensure it is accessible among ICDs across the whole of NHS GGC. The Oversight Board notes that the Independent Review recommended that those with IPC as part of their job role should undergo regular performance appraisal; this should be considered as part of this work, both by NHS GGC and ARHAI Scotland as part of wider work referenced in other recommendations made here.

Recommendation 5: NHS GGC should ensure that there is a full, effective and standardised approach to the relevant microbiological, water testing and other information regarding the QEUH outbreaks. Relevant data should be integrated in a way that allows effective collecting, recording and analysis of information relating to the incidents, which will be reported through the IPC governance system.

264. There was no readily available, clearly organised and accessible database in NHS GGC for recording microbiological typing results to ascertain links between patient and environmental isolates. Such a database would have been valuable in supporting more systematic and longitudinal analysis of the infection outbreaks to support IMTs and any oversight role by the relevant committees. Data has been specifically used and stored with respect to individual incidents and not brought together in a way that would support wider assessments.

265. It is recommended that the Health Board develops a means of bringing the relevant data together for the QEUH and for the period since 2015, to be used going forward. This work should complement the recommendations of the November 2019 HPS report which the Oversight Board understands the Health Board are already implementing. This should be done in conjunction with ARHAI Scotland and HFS with a view to producing a potential exemplar for how to collect and consider such data for future outbreaks experienced by other Health Boards. These bodies should give consideration on how this exemplar can drive change in practice in other Health Boards. Within NHS GGC, the work should be completed by September 2021.

Recommendation 6: IMTs in NHS GGC should be more rigorous in developing and making accessible key documentation to support records and analyses of a series of outbreaks over a prolonged period. This should be implemented by NHS GGC, with support from ARHAI Scotland who can identify best practice and make changes to national guidance if this is required.

266. A lack of systematic development and storage of key documentation for IMTs characterised the period of incidents. This may well have hindered the capacity of the Health Board to recognise and act upon the risk of a pattern of systemic contamination. In particular, there is a need for:

• regular and standardised action logs for IMTs with clear designation of action owners, timescales and active recording of updates;
• a more standardised approach to IMT minute taking with a more rigorous approach to noting and recording key decisions and their reasons (potentially including a Decision Log);
• more regular development, recording and escalation of hot debriefs following IMTs; and

• more regular consideration of whether a full IMT report or SBAR is required for the Acute Infection Control Committee with a view to specific review and application of any lessons learned and recommendations to prevent or better respond to further incidents.

267. It is important that this more comprehensive approach to lesson learning is reflected nationally. ARHAI Scotland should work with other Health Boards and relevant national bodies to consider guidance and systems to support a central repository for IMT and SBAR reports and/or hot debriefs for these (and potentially other) public health incidents through the existing Scottish Health Protection Information Resource (SHPIR) web site. Learning points could be extracted and collated nationally from submitted reports/debriefs to inform future guidance and service improvement, potentially as a regular publication.

268. These actions should be implemented by September 2021.

Recommendation 7: Where there are a number of successive infection incidents in the same or a related location, NHS GGC should work with ARHAI Scotland to pilot a process that goes beyond the current IMT focus on individual incidents on behalf of NHS Scotland.

269. The IMT process lends itself to rapid and effective response to individual incidents, but potentially not to a series of potentially linked incidents. While other parts of IPC governance should provide that wider strategic view, the QEUH experience provides a strong argument for considering other longer-term approaches to addressing such incidents. NHS GGC has already shown the value of this kind of approach with the establishment of the Technical Water Group.

270. A new mechanism may be needed to support better analysis of the results of epidemiological, microbiological and environmental investigations in the round. While there is still a need for IMTs to exert specific controls on individual incidents, a new mechanism could be triggered in particular situations to allow better linking to what was known previously of the infection involved and wider local circumstances. Such a mechanism should review associations which may be considered causal and assess whether there is evidence of bias in the investigation and/or the strength of a specific association. As the Independent Review recommended, IMTs should allow for candid and confidential material to be discussed with a view to continuous improvement.

271. NHS GGC has developed significant experience to be in a position to support the development of such a mechanism. It should work with the Scottish Government and ARHAI Scotland to advise on a process that could be applied across NHS Scotland as a whole. A plan for such work should be developed and presented to the Scottish Government for September 2021.

Recommendation 8: Building on work already in place, there should be further visible and systematic planning for strengthening coordination between IPC and Facilities and Estates, particularly with respect to forward planning in addressing continuing infection risks with the QEUH and specifically in relation to water testing.

272. A key reason for the apparent 'loss' of the DMA Canyon report was the structure and conduct of Facilities and Estates at that time, not least the apparent lack of clarity over the roles and responsibilities within the team. The issues here have been rehearsed in the Independent Review report, and the Oversight Board acknowledges that the structure of the Facilities and Estates team has since changed. There is assignment of specific roles and responsibilities, and with the appointment of the new Director of Facilities and Estates, a greater level of formal compliance systems was introduced within the organisation and formal training and appointment of Approved Persons, not only for water, but for other systems as well.

273. Nevertheless, there are still areas where scope for improvement can be highlighted. For example, the Interim Report noted that the evidence that HAI-SCRIBEs for low-risk/maintenance projects were systematically being reviewed by both Facilities and Estates and IPC colleagues was not apparent. Building on the notable improvement in how Facilities and Estates supports IPC across the organisation, NHS GGC should develop a more systematic approach to reviewing and deepening the coordination between IPC and Facilities and Estates functions, particularly with respect to the QEUH. The Health Board should ensure this approach is consistently reflected in the membership and joint working of key groups and oversight committees that focus on IPC and Facilities and Estates functions. Moreover, it should feature explicitly in the work programmes being developed to support the Silver Command strand of work.

Governance and Risk Management

274. Recommendations are set out here with respect to how IPC governance and risk management within NHS GGC should be improved.

Recommendation 9: The experience of NHS GGC in addressing the unique challenges of the QEUH should be systematically used to shape NHS Assure as early as possible. This should be part of a comprehensive process of developing a template for a 'ward-through-Board' governance system that ensures risks of this nature are appropriately escalated and de-escalated.

275. The knowledge and experience gained by NHS GGC staff, especially those who were involved in the IMTs that investigated the infection incidents, should not be lost. Their knowledge and experience should be retained, capitalised on and utilised in future, not just for local improvement but for national benefit. Particular consideration should be given to establishing a specialist group within the Health Board, with relevant, experienced staff invited to join. If further incidents did occur, the group could provide advice, support and expertise in investigation and action. This could quicken the process of any future investigations as the group would have the benefit of 'hindsight' from previous experience, potentially having a better idea of what to look for and what to consider in these circumstances. This should also take account of the Independent Review's recommendation that governance ensures that hypotheses are sound, contestable and the debate that strengthens or removes hypotheses is respectful and transparent.

276. In addition, as soon as appropriate, the Scottish Government should facilitate an effective transfer of relevant learning from NHS GGC to the new national Centre for Expertise and ensure that the maximum use is made of that learning. This could take the form of working with the specialist group above or formal engagement with the Health Board on 'lessons learnt' on particular infection issues to inform the early priorities of the new Centre's work programme. In preparation, NHS GGC should be invited to capture good practice and learning from its handling of the infection incidents to inform both local and national practice, taking account of these findings and recommendations and the work of the Independent Review.

Recommendation 10: The Health Board should finalise and implement its IPC Assurance and Accountability Framework.

277. The Oversight Board welcomed the Health Board's creation of the IPC Assurance and Accountability Framework and found it a very useful compilation of key documents fashioned into a single appropriate collection of guidance. That document has not been finalised, in part in anticipation of the outcome of the Oversight Board process. NHS GGC should revise the document to take account of changes arising from its Silver Command work and the recommendations set out here and in the Interim Report, and put it into operation by September 2021. That should include a clear governance structure for IPC and the escalation of issues.

Recommendation 11: A review should be undertaken of how the environmental risk of significant water contamination within the QEUH is being assessed and managed in the Health Board's approach to risk management, and changes made to relevant risk registers and risk management planning as a result.

278. As risks are conveyed up the governance structure, they are bound to be compressed in ways that may result in risks becoming less specific. Given the size of NHS GGC, it should not be surprising that capturing such risks with sufficient specificity can be particularly difficult. However, the lack of a clearly-articulated risk associated with the QEUH environmental situation has been notable. Indeed, it would be prudent to expect that the risks may continue in light of the significant issues uncovered in the building. These should be articulated clearly within the Corporate Risk Register as a potential risk to patient safety.

279. NHS GGC should set out how the risk of water contamination in the QEUH, as described in key external reports, will be captured on the governance and risk management systems to allow for early identification, monitoring and management of increased risk. Consideration should be given to conducting further review to gain a greater practical understanding of the risk process. This should include how in practice risks are identified at the ground level and fed up the risk process through the various committees to the Corporate Risk Register, specifically with reference to infection issues. This review of the treatment of such environmental risks should be completed by September 2021.

280. Related to this work, NHS GGC should ensure that the Gold and Silver Command work is subject to children's rights and wellbeing impact assessment processes and their results noted in the next three-yearly report required by relevant legislation.

Recommendation 12: The Health Board should set out a clearer, more targeted focus on the corporate risk process.

281. In terms of risk, there was a lack of transparency as to how environmental risks were escalated within the structure of IPC governance. There is a disconnect between the concerns expressed by many at the 'ground level' with those articulated in the Corporate Risk Register.

282. One way to strengthen the approach to risk would be a clearer designation of responsibility within the governance structure. The Oversight Board understands that a Senior Risk Officer has been appointed – it is hoped that this will achieve a more dedicated focus on the risk process. The aim of such an appointment would be to ensure that each risk area receives the appropriate individual focus that is required within the organisation with direct reporting to the Board itself. The transparency of the risk process needs to be clearer and the role of a chief risk officer would be to ensure that this transparency is achieved. Across the pillars of governance (clinical, financial and staff), it would provide assurance that where required, risks would be escalated quickly to the Board to ensure issues are addressed appropriately and without delay. This should be considered as an early priority in the wider Governance work being led by the Board Chair.

283. The Health Board should set out its plans for this role by June 2021.

Recommendation 13: The Health Board should review how concerns raised about environmental risks are communicated to senior Committees and the Board, and the procedures to ensure that such concerns are addressed. Moreover, it should also ensure the responses are communicated appropriately to those raising concerns.

284. While the Oversight Board did not review how individual concerns and addressed internally within the Health Board – as these have been addressed through separate whistleblowing processes – there are more general points that should be made about how significant concerns of environmental and IPC risks can be raised within the governance structure.

285. One approach is to consider whether there should be more formal and regular updating of the Board Infection Control Committee and the Clinical and Care Governance Committee by the Lead ICD. This happened periodically through the set of infection outbreaks, but a regular reporting to these committees would facilitate how these committees can fulfil their oversight roles and ensure relevant escalation of issues.

Communication and Engagement

286. Some recommendations for communications and engagement have already been set out in the Interim Report. These are not repeated here.

287. The Final Report recommendations address the remaining issues, particularly how the organisational duty of candour policy has been applied by the Health Board.

Recommendation 14: Given that organisational duty of candour was considered, but not formally activated, NHS GGC should review its approach to ensure that it is not simply focused on patient safety incidents and circumstances where causality is clear. There should be greater consideration of the duty where events could result in death or harm. There should also be improved guidance on how the Health Board will balance with other duties perceived as barriers to meeting the organisational duty of candour obligations.

288. NHS GGC undertook benchmarking of its organisational duty of candour response to the infection incidents, which was done on what appeared to be an informal basis. The Health Board is asked to undertake a review of its supporting policy and procedures to support implementation of the organisational duty of candour, outline the interface with the professional duty of candour and support decision-making when there are concerns about competing organisational duties of confidentiality with respect to incidents involving more than one relevant person. It should provide feedback to the Scottish Government on how this is addressed and any areas where revisions to national non-statutory guidance would be helpful. This should include how revised implementation support materials regarding the duty and multiple instances of HAI might be developed through HIS. This should be completed by September 2021.

Recommendation 15: The findings of the Oversight Board in respect of the application of the organisational duty of candour in NHS GGC should be considered by the Scottish Government and Healthcare Improvement Scotland in order that further implementation support and guidance can be developed around the issues noted.

289. NHS GGC suggested that they might not be alone in their ambiguous approach to applying the organisational duty of candour in situations where causality is not easily understood, and other Boards might be experiencing similar challenges in interpreting the legal duty. The Oversight Board could not explore this in detail within the scope of its work, but have asked teams in the Scottish Government and HIS to consider ways in which national guidance and implementation support plans take account of this feedback from NHS GGC. It notes that similar recommendations about the opportunity for national learning were made by the Independent Review in this area, and endorses those recommendations.

General Issues

290. The final set of recommendations relate to technical matters arising from the infection incidents and other more general matters.

Recommendation 16: The Health Board should expedite the refurbishment of Wards 2A and 2B in the RHC as safely and quickly as possible, and keep affected children, young people and families fully informed of the developments.

291. The Interim Report noted that work on refurbishing Wards 2A and 2B had been delayed owing to the impact of the pandemic and the extent of work needing to be undertaken. It is essential that children and young people are returned to the clinical environment specifically designed to support their care as soon as can be safely done. Any further delays should be clearly and readily explained to patients and families.

Recommendation 17: A programme of testing and review should be put in place to assess any potential impacts of the chemical dosing water solution on infrastructure.

292. NHS GGC should ensure that there is monitoring of the potential impact of the chemical dosing system on the existing building and infrastructure of the QEUH site. The Oversight Board is assured of the diligence of the Technical Water Group and the Health Board more generally to ensuring that the system would not put any undue pressure on the integrity and quality of the water infrastructure. Nevertheless, the solution is a radical one that should continue to be monitored, not just with respect to its outcomes (through water testing), but any potential unintended consequences on the infrastructure.

Recommendation 18: The various action plans and reviews attached to these recommendations should be compiled into a single response to the Oversight Board, and implementation overseen by NHS GGC and the Scottish Government.

293. The recommendations set out here (and in the Interim Report) call for a number of actions. These should be compiled into a single plan, integrated into and fully complementing the work of Silver Command. It should be jointly reviewed by NHS GGC and the Scottish Government at appropriate intervals.

8.3 The Way Forward

294. The recommendations signal that the Oversight Board does not think the Health Board can be de-escalated from Stage 4 at this point. NHS GGC is embracing the need and opportunity for improvement and taken a number of decisive steps in IPC and governance. Its energy and commitment is laudable in this context. Nevertheless, the Oversight Board has identified a number of areas where improvement needs to take place before de-escalation can be recommended. Progress in addressing the recommendations will be essential for the Oversight Board to take a final view on advice for de-escalation (and for the national recommendations, to ensure that NHS Scotland learns and acts on the relevant lessons).

295. Ultimately, it is not a question of a checklist of recommendations, but an understanding of 'what good looks like'. The Health Board should embrace this spirit of improvement, and its work to restore confidence and assurance should be measured against achievement of a set of measures of what good IPC should look like. The Oversight Board has set out its view of this in the Key Success Indicators presented in the annex, and invites the Health Board to consider – and build – on these to create a culture of continual improvement, sensitivity to risk, openness and respect in its communications and engagement, and challenge and rigour in facing the unusual public health challenges it faced in these incidents.

296. The Oversight Board has concluded this phase of its work. The Scottish Government will put in place continuing arrangements to ensure oversight of this work going forward. It is proposed that the Chief Nursing Officer and the Chair of NHS GGC jointly agree on an appropriate point when a review can be conducted and a further view on escalation can be taken.