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

Background and Approach

Context for Escalation

11. On 22 November 2019, the decision was taken by Malcolm Wright, Director-General for Health and Social Care in the Scottish Government and Chief Executive of NHS Scotland, to escalate NHS GGC to Stage 4 of the NHS Scotland Board Performance Escalation Framework. In a statement about the establishment of the Oversight Board, the Cabinet Secretary for Health and Sport, Jeane Freeman, said:

"Families deserve to have confidence that the places they take their children to be cared for are as safe as they possibly can be. That means their engagement with their Health Board must be open, honest, and rooted in evidence. This is even more important in the tragic circumstances where a child's life is lost. It is, in my view, simply cruel for the grief of a parent to be compounded by a lack of clear answers… I want now to set out the action and steps we are taking to give parents, families and patients the answers they legitimately seek and to, step by step ensure that we are working on evidenced data, putting in place all the required infection prevention and control measures and by doing so secure the confidence of clinical teams, patients and families."

12. Escalation came against a background of a series of infection issues affecting children and young people in the paediatric haemato-oncology service at the QEUH and the RHC over a number of years. A handful of cases of children and young people with infections occurred in 2016 and 2017, but concerns mounted between January and September 2018 when the number and diversity of type of infections increased. According to Health Protection Scotland (HPS), there were at least 23 cases, involving 11 different organisms. Water testing in Ward 2A in 2018 identified contamination of water outlets and drains, and as a result, control measures were put in place, including sanitisation of the water supply to Ward 2A and installation of point-of-use filters in wash hand basins and showers. Despite these measures, concerns remained and in September 2018, more drastic steps were taken when Wards 2A and 2B in the RHC were closed and the children and young people were moved to the main QEUH building. Concerns about the water supply led to installation of an enhanced water-testing regime and a chlorine dioxide dosing system, first operating across the RHC in late 2018, then the QEUH in 2019.

13. An additional series of infections in 2019 in Ward 6A in the QEUH heightened concerns, and eventually led to the temporary closure of that ward to new patient admissions. Media reports claimed several deaths of patients were linked to infection in the hospital, raising further concerns among patients and families about safety. There was increasing dissatisfaction among some families at the level and quality of communication by NHS GGC throughout this period, leading to the appointment of Professor Craig White by the Cabinet Secretary for Health and Sport in October 2019 as a lead contact and facilitator for the families. In addition, internal NHS GGC reports came to light that suggested that some of the problems with the QEUH site had been identified as early as 2015, but did not appear to have been acted upon at the time (although they were at a later stage).

14. This occurred against a background of concerns that had been consistently raised by several clinicians at the QEUH about the potential environmental risks of the building and the link to emerging infections. Some of these concerns dated back to the period of the completion and handover of the new building. Some of the clinicians did not feel that their concerns – particularly about water and ventilation and the risk of their contribution to infection of such a vulnerable patient population – were being effectively addressed, and in some cases, formal whistleblowing procedures were triggered. These issues were raised in correspondence with the Cabinet Secretary for Health and Sport and featured in evidence submitted to the Scottish Parliament's Health and Sport Committee. The Oversight Board has reviewed this evidence.

15. Finally, there were a number of relevant reports by external bodies over the period that underlined these various concerns. This included the report undertaken by HPS, which was invited to examine the infection incidents by the Health Board. Its report – Queen Elizabeth University Hospital/Royal Hospital for Children: Water Contamination Incident^[3] – was published in February 2019. As well as setting out a number of recommendations for NHS GGC and for national action, the report recognised that the environmental risks of the hospital could not be discounted.

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

17. The decision to move a Health Board to Stage 4 is made on the advice of the Health and Social Care Management Board of the Scottish Government. In the case of escalation to Stage 4, consideration of the Health Board's position within the Escalation Framework would normally be prompted by the identification of significant weaknesses in particular areas considered to pose an acute risk to the following issues: financial sustainability; reputation; governance; and quality of care or patient safety (or in some cases, by a Health Board failing to deliver on the recovery actions agreed at Stage 3).

18. Action typically takes the form of a transformation team led by a Scottish Government Director, Board Chief Executive or other responsible person appointed by the Director-General of Health and Social Care in the Scottish Government and Chief Executive of NHS Scotland to support the delivery of sustainable transformation. The Health Board Chief Executive continues to act as Accountable Officer and be responsible for matters of resource allocation to deliver any transformation plan. The Board Chief Executive and the executive team are expected to work in conjunction with the appointed transformation Director to construct required plans and take full responsibility for delivery.

19. In the case of the escalation of NHS GGC to Stage 4, the transformation Director is Professor Fiona McQueen, the Chief Nursing Officer for Scotland. She has been supported in the programme of transformation by the Oversight Board, and individuals appointed to work within and with NHS GGC, notably Professors Bain, Wallace and White.

20. In February 2020, NHS GGC was escalated again to Stage 4 for a range of issues beyond IPC, governance and communication and engagement; these included performance management on waiting times, the Board's out-of-hours service and financial matters. Work on these escalation issues is overseen by a separate Performance Oversight Group, chaired by John Connaghan (interim Chief Executive of NHS Scotland), thought it has had to suspend work as a result of the pandemic. Its programme of work has not informed this Interim Report, although the Oversight Board has been careful not to duplicate areas being covered more thoroughly by this companion group.

The NHS Greater Glasgow and Clyde/Queen Elizabeth University Hospital Oversight Board

21. The purpose of the NHS GGC/QEUH Oversight Board has been to ensure NHS GGC takes the necessary actions to restore and enhance public confidence in safe, accessible, high-quality, person-centred care at the QEUH and RHC with respect to the matters on which the Health Board was escalated. It will advise the Director-General of Health and Social Care in the Scottish Government and Chief Executive of NHS Scotland when steps have been taken – as set out in the Cabinet Secretary's statement in November 2019 – to restore "confidence that the places families take their children to be cared for are as safe as they possibly can be." In particular, the Oversight Board aimed to:

i. ensure appropriate governance is in place in relation to infection prevention, management and control;

ii. strengthen practice to mitigate avoidable harms, particularly with respect to infection prevention, management and control;

iii. improve how families with children and young people being cared for or monitored by the haemato-oncology service have received relevant information and been engaged with;

iv. confirm that relevant environments at the QEUH and RHC are, and continue to be, safe;

v. oversee and consider recommendations for action further to the review of relevant cases, including cases of infection;

vi. provide oversight on connected issues that emerged;

vii. consider the lessons learned that could be applied across NHS Scotland; and

viii. provide advice to the Director-General of Health and Social Care in the Scottish Government and Chief Executive of NHS Scotland and Scottish Ministers about the escalation status of NHS GGC.

22. This Interim Report sets out the Oversight Board's view on the Health Board's progress in addressing several (but not all) of the issues that led to escalation, and the work that remains to be done. This is a 'first phase' report; it does not give a final summation of the Oversight Board's activity and conclusions, which will come in the Final Report, and address the overarching questions posed about the Health Board's 'fitness for purpose' on these specific matters. In particular, the Oversight Board has not been able to conclude its work on point v in the list above, as the Case Note Review is vital to this, and the Review will not conclude its work until early next year. As a result, the Oversight Board will not examine individual cases or incidents, as these are being covered by the Case Note Review.

23. There are other areas the Oversight Board is not reviewing, particularly where they are being addressed by other processes. In particular, a full accounting of the issues around the building of the hospital is the responsibility of the Hospitals Public Inquiry. The Inquiry is chaired by the Right Honourable Lord Brodie QC PC. Its Terms of Reference have now been published^[4] and the Inquiry has formally started. The Oversight Board is not pre-empting this work, but has necessarily covered similar territory in some instances as part of its own remit. It has done so with the intention of collecting sufficient evidence to take a view on assurance on NHS GGC's current systems, and thereby set out the actions that should be taken to achieve any necessary improvements.

24. Care has also been applied when considering issues raised as part of whistleblowing procedures, which have been activated by some clinicians within NHS GGC in relation to these infection incidents. Much of the substance of the issues raised has been necessary for the Oversight Board to review, and we are particularly thankful for the generous support and courage of those clinicians in raising them to the Cabinet Secretary and to the Scottish Parliament. It has been important that the Oversight Board's work does not cut across these whistleblowing processes, and for that reason, the Oversight Board does not offer a view on any specific internal matters directly relating to these procedures.

Key Working Relationships

25. The Oversight Board established three Subgroups with necessary experts and other participants, with the Scottish Government providing the Secretariat. It commissioned a number of key reports to support its programme of work. Overall, the Oversight Board met on nine occasions between December 2019 and March 2020, when meetings were temporarily suspended because of the Covid-19 pandemic. Further meetings took place in September and October to review all of the relevant materials and agree the Interim Report. Each of the Subgroups had a similar calendar of meetings.

26. Relationships with key groups and communities have been vital for the work of the Oversight Board. This has been essential with respect to the families affected by the infections. Representatives of the families have been part of the Oversight Board itself (and the Communication and Engagement Subgroup in particular). In addition, extensive use has been made of the 'closed' Facebook page (described in more detail in the Communication and Engagement chapter below) to update patients and families on the Oversight Board's progress. Professor Craig White provided a central communication role as historical and new concerns were raised during the course of this work.

27. The Oversight Board also established a positive and constructive relationship with NHS GGC – a critical element to ensure that there was joint investigation of relevant issues and common agreement on how to improve. NHS GGC has worked with the Oversight Board to develop and deliver improvement plans, working through the appointments of Professors Bain and Wallace. NHS GGC staff helped to source and provide a significant amount of information to support Oversight Board and Subgroup discussions, for which the Oversight Board has been particularly grateful. In this context, special mention should be made of the dedicated and highly responsive Programme Management Office set up in NHS GGC to coordinate participation of the Health Board and requests for information. The Programme Management Office offers a good model of how to coordinate and expedite the provision of information, analysis and engagement for such external review processes. Its work – and the support from relevant staff across the Health Board – has been significant, and should be particularly acknowledged in light of the huge health challenges during the pandemic.

28. NHS GGC staff took part in several meetings of the Oversight Board and its Subgroups as invited participants, although the Health Board representatives were not formally part of these groups. Provision was also made for private discussions by the Oversight Board and the Subgroups where appropriate. The findings and recommendations of this Interim Report are the Oversight Board's alone, though in several cases, they reflect and reinforce actions already being taken by the Health Board. Discussions have been held with the Health Board and extensive feedback provided on the development of the Interim Report.

Governing Principles

29. The work of review and direction in these circumstances can be highly challenging, and given the nature of the subject, sensitive and emotionally charged for the children, young people, families and staff involved. The Oversight Board has adopted a values-based approach, based on NHS Scotland values. These governed the behaviours of the Oversight Board, both individually and collectively to:

• treat all our people with kindness, dignity and compassion;
• respect the rule of law; and
• act in an open and transparent way.

30. Above all, the Oversight Board has been focused on opportunities and requirements for improving existing systems and behaviours. While that needs an understanding of what has happened in the past and how processes operated at different points in the period since the opening of the QEUH, it has all been in the service of assessing the quality and impact of processes in place now. 'History' has been important in reflecting the NHS GGC's own capacity to learn lessons, make any necessary improvements and track the implementation and adequacy of those changes going forward. The Oversight Board has aimed to ensure that learning is captured and implemented locally as well as nationally. It has also highlighted improvements already put in place by the Health Board.

31. The work of the Oversight Board has largely related to a specific patient community within the QEUH, but its focus has widened where larger implications are important to acknowledge. For example, the problems with building the hospital and its links with IPC have potential consequences for other vulnerable patient groups across the site, so assurance has been sought that appropriate actions have been taken on the learning arising from what happened with the paediatric haemato-oncology service.

Priority Issues to Be Examined

32. The Oversight Board has concentrated primarily on structures and procedures and not specific individuals and isolated incidents. These have been central to its role of considering the extent to which assurance can be provided about the Health Board's capability and capacity to deliver on the key areas highlighted in escalation. For the Final Report, the Oversight Board will review the narrative of key milestones to understand the circumstances that gave rise to escalation and provide the essential context for an emerging, progressively more complex set of circumstances. For the key areas it was examining – IPC, governance, and communication and engagement – the Oversight Board set out what 'good looks like' through a set of key success indicators (the full set of indicators is described in Annex D). The aim has been to concentrate on a set of principles for each area that governed how the Oversight Board and its Subgroups pursued investigation and recommendation. These principles have been applied through a focus on a set of overarching questions:

• To what extent can the source of the infections be linked to the environment and what is the current environmental risk?
• Are IPC functions 'fit for purpose' in NHS GGC, not least in light of any environmental risks?
• Is the governance and risk management structure adequate to pick up and address infection risks?
• Is communication and engagement by NHS GGC 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?

33. These questions are threaded through the issues considered in the Interim Report. This report does not make final conclusions on these questions, but a full assessment will be included in the Final Report. The questions also link the key areas that the Oversight Board has been tasked to review in the context of these infection incidents:

• IPC: the processes, structures, relationships and behaviours in place to ensure that there is effective identification of infections, management of outbreaks and incidents, and appropriate preventative and improvement work around these issues;
• governance: the framework and systems in place for the issues and risks associated with infections to be raised and actioned, and the assurance secured within the organisation's senior management that this is happening; and
• communication and engagement: how the issues and implications of incidents and outbreaks are communicated with the children, young people, families and the wider public in line with the person-centred principles of NHS Scotland.

34. The issues are inter-locking. Robust IPC procedures should highlight major issues and risks through the structure of governance and risk management. Strong governance will give clear direction and resourcing to IPC across the organisation and ensure a culture of transparency and responsiveness to patient, family and public concerns. Good communication and engagement should ensure that the decisions with governance and the actions taken forward through the IPC Team are clearly presented to those affected by them.

35. Each set of issues required dedicated assessments. For IPC, the Oversight Board considered NHS GGC practice in light of the infection incidents, focusing on the QEUH (and where appropriate, across the Board), with reference to two key principles, as set out in its key success indicators:

• There is appropriate governance for infection prevention and control in place to provide assurance on the safe, effective and person-centred delivery of care and increase public confidence.
• 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.

36. Similarly, for communication and engagement, the key success indicators that the Oversight Board have used are that:

• Families and children and young people within the haemato-oncology service receive relevant information and are engaged with in a manner that reflects the values of the NHS Scotland in full.
• Families and children and young people within the haemato-oncology service are treated with respect to their rights to information and participation in a culture reflecting the values of the NHS Scotland in full.

The Oversight Board's findings and recommendations should be seen through the 'lens' of these key success indicators.

37. As noted above, the findings and recommendations will be reported across two reports: this Interim Report; and a final Report. Different issues relating to escalation will be covered by the Interim and Final Reports: the table below sets out what issues will be covered by which report. Each set of themes arose from continuing exploration of the escalation issues, an iterative process that led to the emergence of matters requiring investigation at different points in the work programme (as the Terms of Reference note: "(to) provide oversight on connected issues that emerge"). Throughout, the Oversight Board has been careful to ensure that it avoids duplication with other review processes, as outlined above.

Escalation Issue	What Is Covered in This Interim Report	What Will Be Covered in the Final Report
Infection prevention and control	Assurance on a selection of IPC processes/systems in NHS GGC following Peer Review Review of approach to improvement in IPC in NHS GGC Findings and recommendations on the above set of issues	Review of how the infection incidents were addressed by NHS GGC and wider mitigation/responses Review of how different staff have worked together in support of IPC in the QEUH Review of the organisation of IPC leadership Findings and recommendations on the above set of issues and the overarching question of the 'fitness for purpose' of IPC within the Health Board
Governance	Update on work of IPC governance	Review of how infection incidents were escalated and addressed by the NHS GGC governance structure Assurance on how IPC issues are currently escalated and addressed within NHS GGC Review of NHS GGC risk management in light of the infection incidents Findings and recommendations on IPC governance issues, and the overarching question of the 'fitness for purpose' of IPC governance within the Health Board
Escalation Issue	What Is Covered in This Interim Report	What Will Be Covered in the Final Report
Related technical issues	Update on refurbishment of Wards 2A/2B in the RHC	Assurance on NHS GGC's water testing and safety policy in the RHC/QEUH Assurance on plans to address any remedial works relating to infection arising from infrastructure issues on the QEUH site
Communication and engagement	Review of how communication and engagement was undertaken by NHS GGC with the children, young people and families affected by the infection incidents – including findings and recommendations	Review of how the Health Board engaged with families through formal review processes, notably the organisational duty of candour and the Significant Adverse Events Review policy for these infection incidents – including findings and recommendations
Case Note Review	Update of the work of the Case Note Review	Summary of findings and recommendations of the Case Note Review
Review of escalation to Stage 4		Advice on whether/how de-escalation should take place

38. The Oversight Board is conducting its work through the review of key documentation and direct inquiry with NHS GGC involving the experts who took part in the Oversight Board and its Subgroups. For the Interim Report, evidence included:

• the papers and material presented by NHS GGC to the meetings, including minutes of the Board, relevant committees (such as the Board Infection Control Committee and the Clinical and Care Governance Committee) and Incident Management Teams (IMTs), relevant action plans, special presentations and 'situation, background, assessment, recommendation' papers (SBARs);
• material provided previously to the Cabinet Secretary for Health and Sport and the Health and Sport Committee of the Scottish Parliament by several clinicians;
• specially-commissioned, topic-specific SBARs from external experts and statements on specific issues, such as water testing and the progress of refurbishment of Wards 2A and 2B in the RHC; and
• key external documents, such as the Health Facilities Scotland (HFS) report, 'Water Management Issues Technical Review: NHS Greater Glasgow and Clyde – Queen Elizabeth University Hospital and Royal Hospital for Children' (finalised March 2019), and the HPS report, 'Summary of Incident and Findings of the NHS Greater Glasgow and Clyde: Queen Elizabeth University Hospital/Royal Hospital for Children Water Contamination Incident and Recommendations for NHSScotland' (published February 2019).

39. There was no programme of comprehensive interviewing or evidence gathering from individuals and organisations, apart from what was undertaken for commissioned work such as the Peer Review described above. However, specific clarifying discussions were held with some QEUH clinicians that had previously raised concerns about the Health Board, representatives of the affected children, young people and families, and NHS GGC representatives throughout the Oversight Board's programme of work.