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

Introduction

1. In November 2019, NHS Greater Glasgow and Clyde (NHS GGC) was escalated to Stage 4 of NHS Scotland's National Performance Framework as a result of a continuing series of infection incidents at the Queen Elizabeth University Hospital (QEUH) and the Royal Hospital for Children (RHC). The Cabinet Secretary for Health and Sport's letter^[1] to the Scottish Parliament's Health and Sport Committee stated:

"In light of the on-going issues around the systems, processes and governance in relation to infection prevention, management and control at the QEUH and the RHC and the associated communication and public engagement issues, I have concluded that further action is necessary to support the Board to ensure appropriate governance is in place to increase public confidence in these matters and therefore that for this specific issue the Board will be escalated to Stage 4 of our performance framework."

An Oversight Board was established by the Director-General of Health and Social Care in the Scottish Government and Chief Executive of NHS Scotland to address critical issues arising from the operation of infection prevention and control (IPC), governance, and communication and engagement at the QEUH and the RHC.

2. The following Interim Report sets out the findings and recommendations that have been developed to date by this Oversight Board. The report summarises the work on investigation, dialogue and improvement from the Oversight Board's establishment in December 2019 through to October 2020. A Final Report – capturing the results of its remaining programme of work – is due in early 2021.

3. The Oversight Board consists of a group of experts and key representatives drawn from other Health Boards, the Scottish Government and the affected families themselves (full membership is set out in Annex A). Chaired by Scotland's Chief Nursing Officer, Professor Fiona McQueen, the work of the Board has been principally carried out through three Subgroups, each focusing on a specific set of issues.

• Infection Prevention and Control and Governance: this Subgroup has examined whether or not appropriate IPC processes, systems and governance were (and are currently) in place across NHS GGC and what recommendations are needed to strengthen these. It was chaired initially by Irene Barkby MBE (Executive Director of Nursing, Midwifery and Allied Health Professionals in NHS Lanarkshire), and latterly by Scotland's Deputy Chief Nursing Officer, Diane Murray.
• Technical Issues: this Subgroup has focused on relevant specific elements of the technical workings of the hospitals in question, with a particular focus on infrastructure issues. It has been chaired by Alan Morrison, Deputy Director for Health Infrastructure in the Scottish Government.
• Communication and Engagement: this Subgroup has considered the operation of effective communication with the children, young people and families affected by the infection incidents, as well as whether a wider, robust, consistent and reliable person-centred approach to engagement has been evident. In addition, it is examining the organisational duty of candour and other key review processes, such as the Significant Adverse Event Review policy. It has been chaired by Professor Craig White, Divisional Clinical Lead in the Healthcare Quality and Improvement Directorate of the Scottish Government.

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

4. The Oversight Board and the Subgroups have been aided by a number of special reports commissioned to examine specific issues relating to NHS GGC. Of particular importance for this Interim Report is the Peer Review of IPC: led by Lesley Shepherd (national professional advisor to the Scottish Government) and Frances Lafferty (Senior Infection Control Nurse in NHS Ayrshire and Arran), this examined key IPC systems and processes in NHS GGC and how national policy on IPC has been implemented. Its terms of reference are set out in Annex B.

5. Lastly, the work of the Oversight Board was supported by several key individuals appointed to work alongside and within NHS GGC on improvement:

• Professor Marion Bain (Deputy Chief Medical Officer, Scottish Government), who was appointed as the Executive Lead for Healthcare Associated Infection within NHS GGC in December 2019 to set the strategic direction for IPC improvement;
• Professor Angela Wallace (Nurse Director, NHS Forth Valley), who was appointed in February 2020 to work with and succeed Professor Bain as the Health Board's Interim Operational Director for IPC; and
• Professor Craig White, who was appointed by the Cabinet Secretary for Health and Sport in October 2019 to work with the families to address communication issues within NHS GGC (and subsequently, to chair the Communication and Engagement Subgroup).

Their insights informed the Oversight Board's conclusions and their work to date will be set out here and in the Final Report.

6. In parallel, the Cabinet Secretary for Health and Sport commissioned a Case Note Review in her statement to Parliament on 28 January 2020. The Case Note Review is examining the individual case documents of the children and young people in the haemato-oncology service from 2015 to 2019 who had a gram-negative environmental pathogen bacteraemia and/or selected other organisms. It is overseen by Professor Marion Bain and a panel of independent external experts led by Professor Mike Stevens (Emeritus Professor of Paediatric Oncology at the University of Bristol). The work of the Case Note Review is continuing and so does not form part of this Interim Report, though there is an update on progress. It is expected to report in early 2021, and its conclusions will be included in the Oversight Board's Final Report.

7. In addition, the Oversight Board has acted alongside to, though separate from the Independent Review. On 5 March 2019, Dr Andrew Fraser and Dr Brian Montgomery were appointed by the Cabinet Secretary for Health and Sport to lead an Independent Review with the aim of: "establish[ing] whether the design, build, commissioning and maintenance of the QEUH and the RHC has had an adverse impact on the risk of Healthcare Associated Infection and whether there is wider learning for NHS Scotland." The Independent Review's report was published on 15 June 2020.^[2] At various points in this Interim Report, the Oversight Board references issues that have been addressed by the Independent Review, but the latter's report is independent of the work of the Oversight Board. NHS GGC and the Scottish Government have both acknowledged the Independent Review's report and are planning action in response to the recommendations.

8. As with other aspects of public sector activity, the Covid-19 pandemic has proven disruptive to the Oversight Board. From mid-March 2020 onwards, it was not possible to hold regular meetings, as many of its members had vital roles in the NHS Scotland response to the pandemic. This delayed the final stages of the Oversight Board's programme, but it did not substantively alter what was done to reach the findings and recommendations set out here.

9. Following this introduction, the Interim Report consists of several sections:

• Background and approach: the context for the establishment of the Oversight Board and the infection issues within the QEUH and the RHC and the way the Oversight Board has been taking forward its work;
• Infection prevention and control: a review of the issues that gave rise to escalation to Stage 4, particularly the processes/systems and approach to improvement of IPC in NHS GGC, as well as a description of the remaining work for the Final Report;
• Governance and risk management: the full findings on IPC governance will be made in the Final Report, but an update on the work is provided here;
• Technical review: the full findings on the technical review will be set out in the Final Report, but a progress update is provided here;
• Communication and engagement: a review of the way in which the Health Board communicated and engaged with patients and families and an update on the work to be done for the Final Report;
• Case Note Review: an update on progress of this independent examination of the individual children and young people and infection incidents; and
• Interim Report findings and recommendations: the findings and initial Oversight Board recommendations of this Interim Report.

10. In addition, there are several annexes:

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

B. the terms of reference for the IPC Peer Review;

C. the stages of escalation in the NHS Scotland Board Performance Escalation Framework; and

D. the Key Success Indicators identified by the Oversight Board