The Scottish Government's Response to the Vale of Leven Hospital Inquiry Report

Executive summary

The report

On 21 August 2009, the Rt Hon Lord MacLean was appointed by the then Cabinet Secretary for Health and Wellbeing to hold a public inquiry into the occurrence of Clostridium difficile (C. diff) infection at the Vale of Leven Hospital (VOLH) from 1 January 2007 onwards, in particular between 1 December 2007 and 1 June 2008, and to investigate the deaths associated with that infection.

The Vale of Leven Hospital Inquiry Report (hereafter referred to as "the report") was published on 24 November 2014. The report describes serious shortcomings at the VOLH that put infected patients in great jeopardy and unnecessarily exposed others to the risk of cross‑infection. The failings in care were compounded by inadequate structures and scrutiny systems at national and NHS board levels, unclear responsibilities and reporting lines, and a lack of effective management and leadership. The report identifies 34 deaths in the period from 1 January 2007 to 31 December 2008 in which C. diff infection was implicated, but this is likely to be an under-estimate as medical records were not available to the Inquiry Team for all patients during this period.

Scottish Government action

The Scottish Government apologised unreservedly to those affected by the VOLH tragedy. It accepted all 75 recommendations from Lord Maclean's report and committed to taking action to ensure they are fully implemented.

First, the Crown Office & Procurator Fiscal Service and all NHS boards were requested in December 2014 to provide an assessment of progress against 66 recommendations (65 for NHS boards and one for the Crown Office & Procurator Fiscal Service), while the Government undertook a similar exercise for its specific recommendations. Responses were summarised in January 2015 to determine the current status of each recommendation, with initial analysis showing that work had already started on many in line with policies and programmes put in place either prior to or since the outbreak at the VOLH. NHS boards have now been asked to provide a progress update on their original assessment, following consideration and approval by local area clinical forums, area partnership forums and public involvement networks.

The second action was to establish an Implementation Group and Reference Group to oversee the implementation process of all 75 recommendations. The Implementation Group, established in February 2015 and chaired by the Chief Nursing Officer, will work with a number of existing groups and inspection and scrutiny organisations to take forward the recommendations. The Reference Group has representatives of patients and families affected by the outbreak whose role is to support and challenge the Implementation Group and ensure the recommendations are fully enacted.

The third action relates to how the Scottish Government, NHSScotland and other organisations will collaborate to go even further than Lord MacLean's recommendations. Examples include the Chief Medical Officer working with the UK Government on a five-year plan to promote better antibiotic prescribing, the Chief Nursing Officer working with Scotland's executive nurse directors to evidence and assure the quality of care provided in an open and transparent way, the streamlining of national healthcare associated infection groups and the development of a five-year strategy to 2020, and the introduction of a new uniform for senior nurse leaders, making them easily identifiable for patients, families and carers.

It is essential to ensure that the lessons of Lord MacLean's report are learned quickly across the healthcare system to prevent a tragedy such as that witnessed at the VOLH from happening again. The fourth action is therefore to introduce a national approach to assuring nursing and midwifery care and ensure that quality of care reviews being developed jointly by Healthcare Improvement Scotland, the Scottish Government and NHSScotland consider how the report's recommendations can be included as part of quality, scrutiny and improvement processes.

The Scottish Government is confident that robust arrangements such as these, operating alongside existing systems described throughout this response, will highlight problems early and trigger actions when things need to be put right.

This response

This response presents evidence of activity in Scotland since 2007/08 that is relevant to the broad areas of interest to the Inquiry and the recommendations it produced, and sets out what more the Scottish Government intends to do. It should be considered in tandem with the implementation plan being developed by the Implementation and Reference Groups, which will set out in detail how, and by when, the recommendations will be enacted fully in Scotland.

Issues identified in the report are addressed under three themes: oversight and leadership (Chapter 2); preventing and controlling infection (Chapter 3); and professional practice (Chapter 4). These chapters identify report recommendations relevant to each of the themes - all 75 recommendations are covered across the chapters, some more than once - before setting out brief details of legislation, policy and other initiatives put in place since 2007 (and, in some cases, prior to 2007) that address core elements of the themes.