- 10 May 2021
Attendees and apologies
- Fiona McQueen, Chief Nursing Officer, Chair of the QEUH Oversight Board
- Craig White, Healthcare Quality and Improvement Directorate, Scottish Government, Chair of the Communications and Engagement Subgroup of the QEUH Oversight Board
- Alan Morrison, Finance Directorate, Scottish Government, Chair of the Technical Issues Subgroup of the QEUH Oversight Board
- Diane Murray, Deputy Chief Nursing Officer, Chair of the Infection Prevention and Control and Governance (IPCG) Subgroup of the QEUH Oversight Board
- Hazel Borland, Executive Director of Nursing, Midwifery and Allied Health Professionals and Healthcare Associated Infection Executive Lead, NHS Ayrshire and Arran
- John Cuddihy, Families representative
- Keith Morris, Chief Nursing Officer’s Directorate, Scottish Government, Deputy Chair of the QEUH Oversight Board
- Lesley Shepherd, Chief Nursing Officer’s Directorate, Scottish Government
- Sandra Aitkenhead, seconded to Chief Nursing Officer’s Directorate, Scottish Government
- Angela Wallace, Interim Director of Infection Control, NHS GGC
- Helen Buchanan, Executive Director of Nursing, Midwifery and Allied Health Professionals and Healthcare Associated Infection Executive Lead, NHS Fife (for the IPCG Subgroup)
- Martin Connor, Infection Control Doctor, NHS Dumfries and Galloway (for the IPCG Subgroup)
- Christina Coulombe, Infection Control Manager, NHS Lanarkshire (for the IPCG Subgroup)
- Marion Bain, Deputy Chief Medical Officer, Scottish Government (for the Case Note Review)
- Carole Campariol-Scott, Chief Nursing Officer’s Directorate, Scottish Government
- Jim Dryden, Chief Nursing Officer’s Directorate, Scottish Government
- Phil Raines, Chief Nursing Officer’s Directorate, Scottish Government
- Dr Andrew Murray, Medical Director, NHS Forth Valley and Co-chair of Managed Service Network for Children and Young People with Cancer
Items and actions
Update on Oversight Board work programme and plans for reporting
Phil Raines reported on progress with different key programmes of work.
Work is on course to conclude early in 2021. Rather than delay any reporting within 2021, Fiona McQueen had agreed with the Cabinet Secretary that the Oversight Board should consider separating its reporting into 2 reports, with an ‘Interim Report’ coming out before the end of 2020. The Interim Report would focus on the work of the Communications and Engagement Subgroup and the Peer Review for the IPCG Subgroup, as this work had already been concluded and agreed by the Oversight Board, or was on the agenda for today’s meeting. A draft of the Interim Report had been prepared for the Oversight Board’s consideration at today’s meeting.
Phil Raines also recommended key additional pieces of work for the Oversight Board to commission:
- a review of HIIORTs relating to the RHC and QEUH infection incidents by ARHAI Scotland and
- a review of the water testing policy for the QEUH site in NHS GGC by Health Facilities Scotland
The Oversight Board agreed to these recommendations.
The Case Note Review is also expected to be completed early in 2021. Professor Mike Stevens is to be invited to the Oversight Board to report on the Case Note Review’s progress at its next meeting.
Draft Interim Report
Phil Raines introduced the draft Interim Report, and summarised its key findings and recommendations, as well as the issues that would be covered in the Final Report.
Oversight Board members welcomed the document and their comments included:
- the report was felt to be well balanced and set out clearly the areas for improvement within NHS GGC, as well as across NHS Scotland
- one of the recommendations (7) needed to be more clearly expressed
- any further peer review work within NHS GGC should be led by the IPC team within the Health Board
- the Case Note Review’s progress should be summarised and
- there needed to be evidence of implementation and positive change arising from the recommendations by the Health Board – indeed, in due course, an implementation plan would need to be set out by NHS GGC
- the report would become a key document for learning and improvement by other Health Boards
- the Final Report should cover the organisational duty of candour and other key review processes, such as SAER policy
The Oversight Board endorsed the draft report.
Fiona McQueen explained that the next steps would entail sharing the draft with NHS GGC for comments. Publication should still be possible before the end of 2021.
- all should consider any further and final comments on the draft and pass to Phil Raines within a week of the Oversight Board meeting
Discussion of Mycobacterium Chelonae cases
John Cuddihy had requested that the Oversight Board discuss the incident of MC cases within the QUEH and how that might be included with the consideration of gram-negative environmental bacteria incidents. He argued that the Health Board’s handling of MC cases was just as important for the Oversight Board in terms of the issues highlighted for escalation.
Members of the Oversight Board commented that it was difficult to comment on the detail of these cases without further consideration. Fiona McQueen asked Phil Raines to work with John Cuddihy to review the cases and the evidence that had already been presented to the Oversight Board.
- Phil Raines will work with John Cuddihy to review the evidence of MC cases and consider whether and how to reflect in the final report
John Cuddihy explained that he had already engaged with Lord Brodie and the Public Inquiry Secretariat about engagement with the families.
It was agreed the next, and potentially last meeting of the Oversight Board would take place in January 2021 (date to be confirmed).