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

Interim Report Findings and Recommendations

167. The core of the Oversight Board's work has been the issue of assurance. Escalation has arisen from a history of complex issues since at least the opening of the QEUH, but the primary matter that gave rise to escalation to Stage 4 was a question of the 'fitness for purpose' of NHS GGC relating to: how IPC is conducted; the way that governance operates with respect to infections; and the communication and engagement approach to these events. Understanding the history of what has happened to the children, young people and the families in the paediatric haemato-oncology service and the clinicians that have supported them has been essential for the Oversight Board. Knowing this history is critical in ensuring that the right lessons have been learned and in further considering the current fitness of the structures and functions of NHS GGC within the Oversight Board's terms of reference.

168. Ultimately, the main question before the Oversight Board has been whether NHS GGC should be 'de-escalated' from Stage 4. As this is an Interim Report, the Final Report will provide a final assessment of all the issues that gave rise to escalation, the contributory factors, the learning and improvement evident to date from the Health Board – and ultimately, assurance on the issues on which NHS GGC were escalated. Notwithstanding that this remains work in progress, this Interim Report has already identified a number of areas where improvement needs to take place for that assurance to be robust. This forms the basis for the findings and recommendations set out in this chapter. The Final Report will set out the conclusions from the rest of the Oversight Board's work, taking account of the Case Note Review, and provide the full list of recommendations.

Findings

169. Findings are given for each of the different issues that led to the Health Board being escalated to Stage 4. Of the three areas for escalation, one – governance – is not examined in detail in the Interim Report. In addition, the work of the Technical Issues Subgroup has not been finalised for this report either, as noted above. Consequently, the findings (and recommendations) here focus on major elements of the two following areas: IPC; and communication and engagement.

Infection Prevention and Control: Processes, Systems and Approach to Improvement

170. Expectations around the scope and pursuit of IPC have changed over the last few years, reflecting, amongst other things, the impact of the Vale of Leven Inquiry. The Inquiry had a major impact on NHS GGC, of course, but it has changed the national context for ensuring that there are consistent, good-practice and evidenced approaches to effective, safe IPC. This has not been a single point of national transformation, but a continuing drive for improvement, one that will continue with the creation of a national centre of expertise for healthcare built environments. The constant evolution of a Scotland-wide agenda in IPC highlights both the challenges that the Health Board faced in addressing the infection incidents in the QEUH site – which presented complexities and unexpected issues that were far from recognised experience in Scotland – as well as the opportunities for using NHS GGC's learning to support NHS Scotland as a whole.

171. What has become clear is the importance of all Health Boards to balance a commitment to these national standards and the codified processes that they set out, rooted in evidence-based good practice, with the flexibility and professional judgement to go beyond set processes where required. Practice has been captured in national guidance and standards with clearly-established reporting and monitoring regimes. Finding that balance has been essential to be able to respond to the new situations and developments in infection control, as indeed, the current pandemic is exemplifying to an alarming degree.

172. NHS GGC showed itself capable on repeated occasions of achieving that balance. Outside of these infection incidents, the recognition of the need to drive improvement was present in its work on CLABSI (and more widely, Methicillin-resistant Staphylococcus aureus (MRSA)). In the series of gram-negative infection outbreaks, the Health Board could respond innovatively and positively, with examples including specific responses to incidents (such as the establishment of the Technical Water Group in response to the 2018 'water incident', which will be discussed in more detail in the Final Report). That work is continuing through the recent reforms put in place in NHS GGC through a new 'Gold Command' structure and the formation of a dedicated programme of work to support improvement in IPC with joint executive leadership from the IPC Team, hospital operations, and Facilities and Estates.

173. However, these instances were not sufficiently consistent to provide assurance. An improvement-based learning approach – vital in addressing circumstances as novel and challenging as the environmentally-based infections in the QEUH – did not appear to be mainstreamed across the organisation. A structured use of quality improvement and good learning in one area did not seem to be systematically mainstreamed across the organisation. The IPC Team was seen as remaining too siloed and not fulfilling its role as the service that embeds improvement and mainstreams good IPC across the Health Board. Recognising recent progress, the Oversight Board welcomes the NHS GGC's creation of a new IPC work programme, and believes that one of its early priorities must be how improvement principles can be deepened in its work.

174. Through the work of the Peer Review, the Oversight Board highlighted a number of specific processes where improvement was required.

• Health Board compliance with the NIPCM was translated through a profusion of additional local guidance and interpretations of national standards, which ran the risk of promoting a 'GGC way of doing things' rather than nationally-endorsed standards.
• HAI-SCRIBEs were not pursued with full diligence and fidelity to process. Too often there seemed to be 'shortcuts' being taken in how HAI-SCRIBEs were put together that suggested a lack of understanding behind the good practice captured in the NIPCM.
• Audit and surveillance showed an inconsistent approach to improvement overall, with insufficient follow-through actions on audits and the absence of a pro-active approach to additional environmental alert organisms in surveillance.
• The scoring of HIIATs raised some concerns that the Health Board was not giving full (and in the Oversight Board's view, necessary) consideration to the wider context of infection at the QEUH site when rating infections. Elements of this issue have a national dimension, and the Oversight Board recognises the opportunity to improve practice across all Health Boards. But in the context of the environmental risks in the QEUH, the approach to HIIATs may indicate an underestimation of the wider infection risks facing the site.

175. The Interim Report has focused on how the IPC Team tackles different aspects of IPC. The Final Report will focus on how the Health Board handled the specific incidents, and what that reveals of the way IPC is conducted by the Health Board.

Communication and Engagement

176. It is hard to imagine a group of children, young people and families for whom the principles of person-centred communication would be more relevant in a healthcare setting. Within the paediatric haemato-oncology service, families were experiencing the sustained impact of the problems in the clinical environment on their children, including significant disruption and uncertainty. Given the nature of the patients, there were high-risk consequences of the issues remaining unresolved – communication and engagement through regular, sensitively-presented and clear information was vital.

177. The Health Board seems to understand this. It espouses person-centred principles in its overarching communication strategies. Indeed, throughout its work, the Oversight Board was presented with a lot of good evidence of a compassionate approach to communication within NHS GGC, especially by staff at the point of care. Families singled out the medical and nursing staff for their support, not least in how they kept themselves and their children as well informed as they could, a clear reflection of the person-centred approach to discussing individual care with patients and families. At this level, transparency and sensitivity seems to be regularly balanced in a way that patients and families regard positively – albeit sometimes limited and constrained by the problems with corporate and senior management communication referred to in this report.

178. However such an approach is inconsistently applied across the organisation. When it comes to communication that goes beyond ward level, too many patients and families feel that it has not been actioned, timely or fulsome, and that they are too often the last to know. This sense accumulated over several years, and it currently strains relationships between some families and the Board (and in a few cases, contributed to those relationships breaking down). Several families have felt that the Board has been too slow, if not reluctant, to provide them with answers to their questions, and have developed a deepening view of a Health Board that cannot admit to mistakes – or even, simply acknowledge uncertainty – about the environment of the building or the care of their children. Wherever the causes lie with this, the results demonstrate a clear failure of the goals of communication for this group of children and young people and their families as a whole. Indeed, the appointment of Professor Craig White, in part a response to the gaps that had appeared between families and the Health Board, has been an acknowledgement of this.

179. From the Health Board's perspective, it is important to understand the challenges facing NHS GGC with communication.

• There was long-term uncertainty in how to explain the infection incidents, especially over the source of infections and the picture of environmental risk that started to appear.
• At some points over the period (notably in the aftermath of the Cryptococcus neoformans infections in early 2019), media coverage was experienced as a 'siege', heightening wariness of how public communication was managed. This created some logistical challenges in ensuring children, young people and their families were given correct information before any misleading or false news spread through the media.
• Those challenges were particularly acute in providing consistent and timely communication with patients and families no longer in regular contact with ward-based staff.

180. The Health Board mainstreamed a commitment to tailored and sensitive responses to individual patients and families through a database to reliably note individual family communication and information preferences. The creation of the closed Facebook page recognised that communication was not simply between individual patients and families with the Health Board, but amongst each other, as part of a community sharing the common experience of a child or young person in contact with the service and concerned by the impact of infection issues on their child's care experience and outcome.

181. The gradual unfolding of the scale of problems at the QEUH, with the emergence of hypotheses relating to the environment and building that could not be quickly verified or discounted, presented particular challenges in communication. The responsibility for decisions in respect of communication about incidents and outbreaks is typically lodged with IMTs, with communication advisors providing support for discussions to inform decisions by IMT chairs. While IMTs were active through this period in response to the infections, the IMT process itself – useful in more incident-based situations – was potentially less effective for a continuing 'crisis'. A new, or at the very least, enhanced process may need to be identified to address this with national support.

182. The recent legal action against the builders of the QEUH complex seems to be complicating the ability of the Health Board to be as open and responsive as patients and families need. There is a risk of the Health Board becoming increasingly reluctant to comment or discuss aspects of what has happened in relation to the infection incidents, citing the risks of compromising the forthcoming legal case. This has exacerbated a sense among several families that NHS GGC has not been pursuing a policy that gives primacy to transparency and sensitivity to the affected children, young people and families. While the Oversight Board appreciates the legal issues facing NHS GGC and the force of legal advice, it considers that alternative approaches were and are possible and that the current continuing silence on many of these issues will not address fundamental concerns on communication and engagement that gave rise to escalation to Stage 4.

183. Lastly, there is a national dimension to this as well. Just as with other aspects of healthcare, there is a clear value in pooling experience and practice in NHS Scotland to address complicated communication challenges and developing national expertise. External bodies such as HPS and others did not have the expertise to providing NHS GGC with advice and support in this area. While the responsibilities may fall locally to NHS GGC, the implications are Scotland-wide, and deserve the same approach to improvement and learning found in other areas of healthcare.

Recommendations

184. The recommendations of the Oversight Board are rooted in the findings described above. As noted earlier, 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. The Oversight Board has been well aware of the novelty of the challenges faced by the Health Board, the absence of national guidance in some areas and the importance of making an assessment that is not distorted by hindsight. They have been driven by the importance of ensuring that there is learning and change to address any similar set of challenges in future, whether within NHS GGC or across NHS Scotland more widely.

185. The recommendations are based on what needs to be done by NHS GGC and others to provide assurance and address escalation. In terms of the Key Success Indicators of the Oversight Board, they identify the changes that are required to satisfy the Oversight Board that these success indicators will be met and assurance restored, at least for the areas reviewed in the Interim Report. The recommendations are grouped according to each set of escalation issues: IPC; and communication and engagement. National recommendations are set out in the green boxes below.

Infection Prevention and Control: Processes, Systems and Approach to Improvement

186. The Interim Report recommendations cover the following key areas:

• the degree to which specific IPC processes in the QEUH have been aligned with national standards and good practice; and
• the extent to which the IPC Team has demonstrated a sustained commitment to improvement in infection management across NHS GGC.

Recommendation 1: With the support of ARHAI Scotland and Healthcare Improvement Scotland, NHS GGC should undertake a wide-ranging programme to benchmark key IPC processes. Particular attention should be given to the approach to IPC audits, surveillance and the use of Healthcare Infection Incident Assessment Tools (HIIATs).

187. With support from ARHAI Scotland and Healthcare Improvement Scotland, NHS GGC should undertake a comprehensive programme of work to address the shortcomings identified here. This should build on the existing Peer Review process, led from within its IPC Team but drawing on external expertise. It should also fit into the existing programme of work being taken forward as part of the Silver Command workstream in the Health Board. The scope and terms of reference should be agreed with the Scottish Government by March 2021.

188. This exercise should be undertaken as soon as feasible (acknowledging the pressure of other circumstances, not least the pandemic), and completed by the end of August 2021. The recommendations of that work should be jointly presented to the NHS GGC Board and the Scottish Government, and the former should authorise an action plan to implement any relevant recommendations.

189. This should include a review of audit programmes to ensure consistency in RAG rating and a stronger link to a continuing culture of improvement. This would help to confirm that there is an organisational approach to safe care auditing, in particular ensuring that it is not the sole responsibility of the IPC team. This should be done in the context of existing Quality Framework for improvement and planning as set out by HIS and involve the latter in a support role.

190. As seen above, the rating of HIIATs for the relevant infections in the QEUH raised concerns about consistency for the Oversight Board. A more in-depth and wide-ranging review needs to be undertaken by NHS GGC, looking at the local criteria and judgements applied to ratings for infection incidents related to the QEUH. Attention should focus on how known environmental risks in the hospital, especially with respect to potential water contamination, are explicitly factored into assessment.

Recommendation 2: With the support of ARHAI Scotland, NHS GGC should review its local translation of national guidance (especially the National Infection Prevention and Control Manual) and its set of Standard Operating Procedures to avoid any confusion about the clarity and primacy of national standards.

191. NHS GGC has not applied the NIPCM as fully and transparently as it could. Moreover, there was a view that not all guidance in the NIPCM was appropriate for NHS GGC. Consequently, NHS GGC should conduct a review of its guidance portal so that clinical staff are referred to the NIPCM and all relevant national guidance (as set out in DL 2019 (23)) more clearly as a single 'point of truth'. This should build on progress already made to feed into national structures, minimising the development of new local guidance. This exercise should set clear, consistent principles for the development of local translations of national guidance, as well as the responsibility for developing, implementing and overseeing the relevant set of standards/guidance. This should be completed by end April 2021 and the results presented to the Scottish Government.

Recommendation 3: ARHAI Scotland should review the National Infection Prevention and Control Manual in light of the QEUH infection incidents.

192. Surveillance issues need to be addressed at national level as well. ARHAI Scotland should review the NIPCM to consolidate and prioritise content in relation to alert organism surveillance. In particular, Appendix 11 and the A-Z guidance list of organisms of the national manual should be enhanced as required so there is national consistency to any aide-memoires developed for clinical staff to use locally. The guidance could benefit from additional disease-specific evidence-based SOPs or aide-memoires for some novel pathogens to be produced nationally. This review should be taken forward in collaboration with the Scottish Government and completed by end August 2021.

Recommendation 4: With the support of Health Facilities Scotland, NHS GGC should undertake an internal review of current Healthcare Associated Infection Systems for Controlling Risk in the Build Environment (HAI-SCRIBE) practice to ensure conformity with relevant national guidance.

193. NHS GGC should undertake an internal review of current HAI-SCRIBE practice against SHFN 30 to check that HAI-SCRIBEs are being developed consistently across the whole of NHS GGC and in line with national guidance. This review should include: the level of engagement and input from the IPC Team to take account of level of risk, as well as the scale of the project; the level and nature of the required input from the IPC Team for projects which are deemed smaller; and the overall use of HAI-SCRIBE and the consistency of use across NHS GGC, including consistency training for those undertaking HAI-SCRIBE. The review should be undertaken in cooperation with HFS and the results presented to the Scottish Government by end August 2021.

Recommendation 5: Health Facilities Scotland should lead a programme of work to provide greater consistency and good practice across all Health Boards with respect to the use of HAI-SCRIBEs.

194. HFS should work with Health Boards across Scotland to develop a governance system for ensuring HAI-SCRIBEs are completed consistently across and within all Health Boards. This should entail the establishment of a national forum to enable better sharing of design issues and lessons learned, with plans and a timetable for the forum to be agreed with the Scottish Government by March 2021. This should be supported by a review of the current HAI-SCRIBE guidance across all Health Boards, which should be led by HFS in cooperation with the Scottish Government and completed by end August 2021.

Recommendation 6: ARHAI Scotland should review the existing national surveillance programme with a view to ensuring there is a sustained programme of quality improvement training for IPC Teams in each Health Board, not least with respect to surveillance and environmental infection issues.

195. IPC teams across Scotland are involved in vast amount of data collection in terms of audit and surveillance. It is vital that this data is used to support both local and national quality improvement in terms of patient outcomes. The Oversight Board recommends that this should include:

• a national surveillance system for Scotland which would seamlessly follow each patient across each interface of health and care – this would ensure that IPC and HP teams have the ability to act timeously where there individuals who may pose a public health risk, such as those who are isolating multi-drug resistant organisms; and
• provision of training for IPC teams regarding quality improvement, utilising the data and intelligence from both audit and surveillance to ensure better outcomes for patients.

ARHAI Scotland, working with the Scottish Government, should set out plans for the required programme of work before the end of August 2021, potentially using the national forum referenced in Recommendation 5 above to develop and monitor the work going forward.

Recommendation 7: ARHAI Scotland should lead on work to develop clearer guidance and practice on how HIIAT assessments should be undertaken for the whole of NHS Scotland.

196. The review of HIIATs found that national improvement is needed. All Health Boards should be encouraged to report all infection-related incidents in an open and transparent manner. To support this nationally, by the end of August 2021:

• ARHAI Scotland should further develop the HIIAT assessment and reporting tools to allow service, ARHAI Scotland and the Scottish Government to visualise easily all incidents within a healthcare facility over time;
• ARHAI Scotland should coordinate a working group through the NIPCM steering group to consider the HIIAT assessment more generally, including a standardised scoring system to provide a more robust risk assessment of infection-related incidents within care systems;
• a programme of work to improve national guidance and good practice should be drawn up to ensure NHS Boards and other organisations IMT consider previous incidents and any possible links when assessing all new infection-related incidents;
• a programme of work to develop education tools nationally to assist staff responsible for assessing and reporting infection-related incidents across NHS Scotland; and
• the Scottish Government should consider the communication and escalation process for all incidents, including a 'green' HIIAT.

Recommendation 8: A NHS GGC-wide improvement collaborative for IPC should be taken forward that prioritises addressing environmental infection risks an ensuring that IPC is less siloed across the Health Board.

197. The Oversight Board welcomes the development of a new improvement collaborative for IPC, and suggests that it takes forward early priorities that address the findings and recommendations set out here. As part of this, to ensure that IPC is more effectively mainstreamed across the different parts of the organisation, a cross-NHS GGC exercise should be undertaken to develop a plan for ensure IPC operates in a less siloed fashion across different service/functions in the Board. That exercise should consider the role of the IPC Team and the aspects of IPC that should be the responsibility of other parts of the organisation and other teams. It should undertake any necessary benchmarking with other Health Boards. The results of the work should be considered by the Board Infection Control Committee and the Clinical Care and Governance Committee. Monitoring arrangements for implementing the plan should be clearly set out as part of this.

198. The scope of the work should be agreed with the Scottish Government and the Health Board by end March 2021 and the work completed by end August 2021.

Communication and Engagement

199. Recommendations are set out below with respect to the overarching question: is communication and engagement by NHS GGC adequate to address the needs of the children, young people and families with a continuing relationship with the Health Board in the context of the infection incidents? Issues relating to how the Health Board formally reviewed these incidents and engaged with patients and families, particularly decisions not to activate the statutory organisational duty of candour procedure and the implementation of review processes such as Significant Adverse Event Reviews, will be considered in the Final Report.

Recommendation 9: NHS GGC should pursue more active and open transparency by reviewing how it has engaged with the children, young people and families affected by the incidents, in line with the person-centred principles of its communication strategies. That review should include close involvement of the patients and families themselves.

200. The particular problems of communicating information on HAI in the paediatric haemato-oncology service – when key information remains uncertain, or at best, nuanced – was acknowledged by the Oversight Board. It was challenging for NHS GGC to balance assurance in its approach to addressing the infection incidents when there was continuing, longer-term uncertainty on the sources of infection. Nevertheless, the focus should remain on transparency and this did not appear to be consistently applied by NHS GGC.

201. In that context, it is vital that there is clear and widespread consistency of messages and information shared in these situations. Similarly, it is critical that the Health Board undertakes a more transparent approach in its communication against any similar background of uncertainty, even if it leads to NHS GGC admitting its inability to answer key questions immediately. Expressing uncertainty should not be seen as detracting from providing reassurance. The Health Board should be more open about what is known and what can be said.

202. This should form the governing principles of a NHS GGC review of how it undertook communication with the affected children, young people and families of the infection incidents and what learning should be taken and mainstreamed. That review should closely involve the families themselves and be presented to the Scottish Government by end June 2021, not least as a source of national learning for other Health Boards. It should focus on the transparency and timeliness of how information was presented and communication experienced by patients and families.

Recommendation 10: NHS GGC should ensure that the recommendations and learning set out in this report should inform an updating of the Healthcare Associated Infection Communications Strategy and an accompanying work programme for the Health Board.

203. NHS GGC should review and renew its existing HAI Communication. A revised strategy – taking account of the learning set out in this report and the actions identified in the recommendations – could become the basis of an exemplar to other Boards, or a plan modelled on national strategic and IPC requirements. This should be completed by end August 2021.

204. Communication and engagement activities were being brigaded together under a 'Silver Command' strand in the new 'Gold Command' structure. As the 'Better Together' work strand develops, there should be a priority in developing a revised version of the strategy with an accompanying action plan and commitment to undertake the reviews set out in these Interim Report recommendations.

Recommendation 11: NHS GGC should make sure that there is a systematic, collaborative and consultative approach in place for taking forward communication and engagement with patients and families. Co-production should be pursued in learning from the experience of these infection incidents.

205. The experience of the communication regarding infections in the paediatric haemato-oncology service has highlighted the need for deploying a range of approaches. This should be routinely pursued through collaborative work with families with direct experience of how best to navigate the complexities of making contact when an organisational or public interest matter may require that. A partnership approach should be explicitly recognised by NHS GGC and actively pursued as part of the 'Silver Command' work programme and reflected in the HAI Communication Strategy referenced in the previous recommendation.

Recommendation 12: NHS GGC should embed the value of early, visible and decisive senior leadership in its communication and engagement efforts and, in so doing, more clearly demonstrate a leadership narrative that reflects this strategic intent.

206. Leadership in addressing the challenge of communication on these infections was clearly demonstrated in much of the response to the emerging issues by senior staff within the hospital. But more senior leadership within the Health Board was not always presented visibly or experienced positively by the children, young people, their families and the public as the situation unfolded in the public eye. The lack of consistency in the approach was a significant issue for some families.

207. NHS GGC should review its approach to ensuring the right tone and sensitivity in handling is pursued in future, especially for its corporate communication, and determine if guidance or training is required to embed the Health Board's learning in this context. There should be more systematic assurance by the Health Board that this is happening across the organisation. This should also ensure that the views and experiences of patients and families remain central to how excellence in healthcare is pursued. Regular reviews of patient experiences and the use of Care Opinion is good, but opportunities for a more targeted review of communication in key incidents by relevant patients and families should be considered. This should build on the recent work led by the Executive Nurse Director as presented to the Board's Clinical and Care Governance Committee. This could take the form of some form of regular monitoring/review on the quality and effectiveness of communication in IPC as part of the revised HAI strategy. The results of that review should be regularly presented to the Care and Clinical Governance Committee, and, where appropriate, the Board.

208. The Health Board should present a proposal for putting these measures in place to the Scottish Government by the end of March 2021 so that it can feed into the development of a revised HAI Strategy.

Recommendation 13: The experience of NHS GGC should inform how all of NHS Scotland can improve communication with patients and families 'outside' of hospitals in relation to infection incidents.

209. There was a challenge for NHS GGC in communicating when it was not person-to-person. That challenge should be explicitly recognised and addressed pro-actively by the Health Board in preparation for any similar future challenges by ensuring its communication infrastructure has a strategic emphasis that recognises and plans and delivers on these principles. This includes due recognition of the role of strategic intent, leadership, skills and culture.

210. That should include learning from and establishing as routine practice the establishment of specific communication channels for patients and families. The example of the 'closed' Facebook page has already been cited, and while it remains a 'work in progress', it has been a key element in restoring good communication with many of the families including a significant uptake in participation. There is an excellent opportunity for national learning, and it is recommended that NHS GGC pursues this through the NHS Scotland strategic communication group in the first half of 2021.

Recommendation 14: The experience of NHS GGC in systematically eliciting and acting on people's personal preferences, needs and wishes as part of the management of communication in these infection incidents should be shared more widely across NHS Scotland.

211. To ensure that people remain at the centre of communication and engagement efforts and that they are listened to, special attention should be placed on ways of capturing communication preferences. This is particularly critical in particular operational services such as paediatric haemato-oncology service. NHS GGC demonstrated useful learning in this context, particularly through the development, updating and use of its database of communication preferences for affected patients and families. There is an excellent opportunity for national learning, and it is recommended that NHS GGC pursues this through the NHS Scotland strategic communication group. It should share learning of the use of the shared database (both software and approach) as well as the mechanism they developed to have single list of all those across service elements receiving care.

Recommendation 15: NHS GGC should learn from other Health Boards' good practice in addressing the demand for speedier communication in a quickly-developing and social media context. The issue should be considered further across NHS Scotland as a point of national learning.

212. The impact of social media on amplifying speculation was presented by NHS GGC as a key challenge, often overwhelming messages, narrative, and the ability to reassure families and present clear information. The Health Board should consider how it can provide more adept and quicker confirmation of lines and messages in this context, guarding against any harmful lag in communication, and how best to make positive and effective use of social media in this context. There is good practice that can be learnt from other Boards around the use of social media in this context, particularly around the value of different types of social media in different contexts. This is an excellent opportunity for national learning, and should be pursued through the NHS Scotland strategic communication group in the first half of 2021.

Recommendation 16: NHS GGC should review and take action to ensure that staff can be open about what is happening and discuss patient safety events promptly, fully and compassionately.

213. Good communications with the staff is important to ensure that staff are well informed and can contribute to supporting the children, young people and their families. This only works if there is a good flow of information from the Board to the point of care, without internal organisational boundaries becoming barriers. Key factors to support this include active, transparent and consistent communication across different, relevant parts of the Health Board. This is also likely to involve empowering and supporting 'clinical voices' to lead, shape and deliver public-facing communication reflecting transparent, respectful and compassionate communication, including the improved use of clinical expertise and voices in corporate responses to media enquiries and briefings.

214. NHS GGC is invited to review its the experience of the communications on HAI in the paediatric haemato-oncology service, and where lessons learned can improve staff communication in future. Plans for taking this forward should be presented to the Scottish Government by end March 2021.

Recommendation 17: The Scottish Government, with Healthcare Improvement Scotland and ARHAI Scotland, should review the external support for communication to Health Boards facing similar intensive media events.

215. While communication and engagement in these circumstances can and should be the responsibility of individual Boards, there are points where there is a clear role of other key bodies in supporting messaging and the flow of information. That role was not clearly and consistently acted upon in these circumstances. Scottish Government, HIS and ARHAI Scotland should review how other bodies should support and engage with individual Boards in similar situations in future, through the NHS Scotland strategic communication group. The Scottish Government should ensure any plans for improvement are developed by end August 2021.