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

Case Note Review

Background to the Case Note Review

159. As part of the work of the Oversight Board, the Cabinet Secretary for Health and Sport set out plans for a Case Note Review in a Parliamentary statement on 28 January 2020. The Case Review team would review the case notes of paediatric haemato-oncology patients in the QEUH and RHC from 2015 to 2019 who had a gram-negative environmental pathogen bacteraemia (and selected other organisms) identified in laboratory tests.

160. The Case Note Review is currently reviewing the clinical records of all children and young people diagnosed with qualifying infections and who were cared for at the QEUH and RHC between 1 May 2015 and 31 December 2019. It is focusing on several key aspects: the number of patients (in particular, immuno-compromised children and young people) who may have been put at risk because of the environment in which they were cared; and how that infection may have influenced their health outcomes. Such work will be vital in determining the number and nature of the children and young people affected, providing assurance and identifying improvement actions, not just for NHS GGC, but more widely across NHS Scotland. It is also an important element in improving the communication and engagement with the affected children and young people and their families.

161. The Review will consider the balance of probability on the following set of specific questions:

• How many children in the specified patient population have been affected, details of when, which organism etc?
• Is it possible to associate these infections with the environment of the QEUH and RHC?
• Was there an impact on care and outcomes in relation to infection?
• What recommendations should be considered by NHS GGC – and, where appropriate, by NHS Scotland, more generally – to address the issues arising from these incidents to strengthen IPC in future?

162. There are two specific sets of outputs:

• reporting to the Oversight Board; and
• specific feedback to patients and families (including responses to questions raised by individual families).

Reporting to the Oversight Board

163. The independent Expert Panel will be responsible for providing a Final Report to the Oversight Board, which will include:

• a description of the approach and methodology to the Review;
• a description of the children and young people included in the Review;
• a description of the cases according to specified data types;
• analysis to answer the questions set out above; and
• observations on any prior NHS GGC internal reviews of individual episodes of care
• recommendations for NHS GGC and NHS Scotland, based on this analysis.

Individual case details will not be set out in the Report and the cases will be anonymised. This Report will be published.

Reporting to Patients and Families

164. The Expert Panel will provide individual private reports to patients and families that have requested details of the results of the reviews on the experiences of the individual children and young people.

Progress Update

165. As with the work of the Oversight Board, the Case Note Review's timescales have been affected by the impact of the pandemic – however, its work has progressed, albeit at a slower pace. The Expert Panel has agreed a classification of relevant infecting organisms, and the case notes of all children and young people defined as follows:

• those with a gram-negative environmental bacteraemia (bloodstream infection) – most patients fall into this group;
• other environment-related infections – there are a few other types of infection which may be associated with the environment (such as M. chelonae), but this includes only a small number of cases, some with bloodstream infection and some with similar infections found at other sites; and
• a smaller number of individual children and young people identified for inclusion for special reasons, where concerns have been raised that are related to the issues affecting the QEUH/RHC.

Currently, 85 children and young people have been identified, and whose clinical records will be reviewed (some have had more than one 'qualifying' infection episode).

166. The Expert Panel has estimated that it will complete its review of the instances of infection and be presenting its report in early 2021.