- 10 May 2021
Attendees and apologies
- Fiona McQueen, Chief Nursing Officer (Chair), Scottish Government Chief Nursing Officer Directorate
- Diane Murray, Deputy Chief Nursing Officer, Scottish Government Chief Nursing Officer Directorate
- Lesley Shepherd, HAI/AMR Professional Nurse Advisor, Scottish Government Chief Nursing Officer Directorate
- Angela Wallace, Nurse Director, NHS Forth Valley (and Interim Director of Infection Control, NHS GGC)
- Sandra Aitkenhead, KPMG Consultant seconded to the Scottish Government
- Hazel Borland, Executive Director of Nursing, Midwifery and Allied Health Professionals and Healthcare Associated Infection Executive Lead, NHS Ayrshire and Arran (joining after 3 pm)
- John Cuddihy, Parents representative
- Craig White, Communications and Engagement Lead, Scottish Government
- Phil Raines, Unit Head, Scottish Government QEUH Business Support Unit
- Carole Campariol-Scott, Policy Officer, Scottish Government QEUH Business Support Unit (OB Secretariat)
- Jim Dryden, Policy Officer, Scottish Government QEUH Business Support Unit (OB Secretariat)
- Marion Bain, Deputy Chief Medical Officer, Scottish Government
- Dr Andrew Murray, Medical Director, NHS Forth Valley
Items and actions
The Chair welcomed everyone to the meeting. She took the opportunity to formally thank a number of colleagues who were previous members of the Oversight Board (OB) for their contributions to the work of the OB, namely: Greig Chalmers, Keith Morris and Marion Bain.
She acknowledged the unprecedented challenges the COVID-19 pandemic brought and which caused for the OB work to be slowed down, but not stopped. One unintended consequence was for the Case Note Review reporting to be delayed to early 2021.
Among the aims of this meeting was to:
- take stock on where the OB was in its work programme. Reports were now available from all the workstreams which had been commissioned, including the Subgroup
- agree on the steps to preparing a final report, including whether an interim report may be necessary, and what other work was needed before the OB could complete its work and
- come to a view to what practical steps to recommend NHS GGC in the report which would make a difference to patients’ safety going forward
It was also noted this was a private meeting without NHS GGC representatives, providing an opportunity for open discussion by the OB.
Infection and Governance Timeline: draft final report
Sandra Aitkenhead (SA) presented her paper to the OB. SA was asked by the OB to create a timeline between 2015 and 2019 of the infection incidents in the
haemato-oncology paediatric patient group, and how they were handled by various groups/committees within NHS GGC. The Chair acknowledged the complex and challenging task in producing the timeline and thanked SA for her work.
SA made the following points:
- the findings were not based on detailed forensic investigation of all information sources, but on documents provided by NHS GGC, which included minutes of meetings of relevant groups and committees
- the timeline had been revised in line with comments made by NHS GGC on an earlier version. It also incorporated comments from a number of NHS GGC clinicians who had raised concerns about the hospital with the Cabinet Secretary
John Cuddihy (JC) acknowledged the considerable work SA had put in to produce the timeline. He also added that the analysis was only as good as the information SA was provided with and asked how confident SA was about the information she had been supplied with. The Chair asked JC whether he thought some of the information was missing, to which JC agreed. SA responded to say the timeline was a factual representation of the information provided in the minutes of the key groups and committees in the NHS GGC clinical governance hierarchy.
Diane Murray (DM) suggested that the Infection Prevention and Control and Governance (IPC&G) Subgroup should examine the timeline and report, and reconvene for a meeting to discuss.
- OB Secretariat to arrange a meeting of the IPC&G Subgroup
IPC and Governance Subgroup: draft summary report
DM summarised the work of the IPC&G Subgroup, as set out in the summary report provided to the OB. She explained that the Subgroup had not yet had the opportunity to review its draft report in light of the comments on an initial draft shared with NHS GGC. The Subgroup should reconvene to consider the comments by the Health Board and agree a final report. DM added the current draft of the report echoed findings in SA’s timeline report.
The key issue for the OB to explore was whether it felt the evidence suggested that NHS GGC’s response to the infection incidents could have been improved significantly.
The aim of the Subgroup report was to ensure that IPC processes and systems and escalation procedures within the Health Board were fit for purpose. While the Subgroup had not been able to conclude its work programme because of the pandemic, it had been able to review a range of issues, including in-depth examinations of key periods. Key areas that needed further consideration included:
- considering issues raised by several NHS GGC clinicians about the effectiveness of IPC arrangements within the Health Board and
- looking at the organisation’s ability to learn, and the deeper implications for the organisation’s culture
Phil Raines (PR) updated on engagement with several NHS GGC clinicians. The three clinicians had contacted the Cabinet Secretary previously with issues relating to IPC, governance and communications. The Chair met with them to hear the concerns in the context of the work of the OB. PR advised that their evidence warranted further engagement with the Health Board before the OB prepared its final report.
JC added that this discussion suggested that not all relevant information may have been provided to the OB yet, citing the example of how some Gram-positive bacteria infection incidents within this group of patients and the timeline of the OB were being regarded. It was agreed that the Secretariat would liaise further with JC to ensure that these issues were properly considered before the final report was prepared.
- PR to liaise with JC on key information gaps in the timeline and IPC&G Subgroup work
Case note review
PR explained that the Case Note Review was part of the OB process, but running to a different timescale. The Case Note Review would examine individual infection cases and draw observations and conclusions for the OB (as well as the individual families). The impact of Covid-19 meant that the work had continued at a slower pace, so the current anticipated deadline to complete the final report is early 2021.
One of the emerging findings related to record-keeping issues within NHS GGC. The Case Note Review team had made a number of observations about record-keeping in a paper to the OB. The findings were recommended to the OB for consideration for its final report.
PR suggested that when the Case Note Review report was completed, the OB should reconvene to consider the findings and recommendations.
On behalf of Lesley Shepherd (LS), PR set out the Peer Review work. LS, Frances Lafferty (NHS Ayrshire & Arran) and Claire McGrath (SG) worked with NHS GGC on bringing the report together. NHS GGC commented on a draft of this report, and Lesley Shepherd considered these comments for her final draft. As a full Peer Review could not be conducted because of the pandemic, the report recommended that such a full Review should be completed on IPC processes in NHS GGC at some stage.
In discussion, DM suggested that she meet with members of the IPC&G Subgroup to discuss key aspects of IPC that could not be covered by the Peer Review. This would be picked up as part of the proposed meeting of the Subgroup.
IPC/organisational development work within the Board
The Chair explained that, following escalation to Stage 4, Marion Bain (MB) and Angela Wallace (AW) were placed within NHS GGC to undertake senior IPC roles. MB had since moved on to take up a new role as Deputy Chief Medical Officer in the SG. Both provided reports on their experiences and the work they had undertaken in NHS GGC. AW was invited to provide her view of the current state of IPC, and what further work might be required.
DM added that these issues had not been explored before in the context of a complex and large organisation such as NHS GGC, and that acknowledgement was required of the different structure and processes to capture all of the issues. Craig White (CW) added that the role of clinical leadership was important in this context, not least the role of the Clinical Care and Governance Committee.
Communications and Engagement Subgroup: final summary report
In presenting the work of the Communications and Engagement (C&E) Subgroup, CW thanked JC, Alfie Robson, Lara Allan (SG), PR and Calum Henderson (SG) in supporting the work of the Subgroup. The C and E Subgroup summary paper had been finalised, following comments by NHS GGC on an earlier draft.
CW acknowledged that over the course of the Subgroup’s work, the relationship with NHS GGC had become significantly less adversarial and real improvements had been noted. Working through the issues had resulted in the following outcomes:
- more senior executive engagement had been noted with the families
- the Subgroup offered consistent transparency, and was a consistent and reliable way to ensure families were demonstrably at the centre of action
- some improvement in thinking more innovatively had occurred, such as the closed Facebook group for the families, giving an opportunity for NHS GGC to embrace social media as one other means of engagement with the families.
The Subgroup had also discussed the issue of the organisational Duty of Candour. NHS GGC reported on the duty of candour as required by legislation, although no events had been activated under Duty of Candour within the period of QEUH infections. The Subgroup had raised issues about the Health Board’s interpretation of the triggers for the organisational Duty of Candour.
JC also acknowledged there had been improvement in the Health Board, but there was still more to do. Engagement with the families had to be a corporate responsibility, especially with the Duty of Candour. It had to be embedded in the organisational culture to allow freedom to talk openly to families. He endorsed CW’s comments and his particular role in engaging with the families especially around the Duty of Candour.
Technical Issues Subgroup
Alan Morrison (AM) reported that he had spoken to the Director of Facilities and Estates at NHS GGC this week to ask for an update on refurbishment of Wards 2A and 2B in the RHC and plans to invite HFS to review the current water safety policy of NHS GGC. On refurbishment, as a result of the pandemic, the revised timeline for completing Wards 2A/B was now May 2021.
Outstanding work: summary and discussion
PR talked through the remaining work that OB should consider taking forward before it prepared its final report. In the ensuing discussion, the following points were made:
- work had been identified which still needed to be done. The OB would need to go back to NHS GGC with specific questions and information requests
- Laura Imrie of ARHAI Scotland would be commissioned by the OB to produce a SBAR on HIIORTs by NHS GGC
- further work on the Health Board’s approach to Significant Adverse Event Reviews would be taken forward
- follow up engagement with the NHS GGC clinicians – and the Health Board itself – was needed on selected issues
The Chair noted the following as part of the discussion:
- the meeting had demonstrated the huge amount of work that the Subgroups and others had done. They were to be thanked for these contributions
- however, to fulfil the OB’s role of providing assurance, it needed to be satisfied that the relevant issues had been explored before the final report was prepared
Final report and next steps: discussion
The Chair thanked all and rounded up the meeting, with the following key questions:
- was there sufficient evidence for the OB to provide recommendations?
- should the OB consider ‘phasing’ the recommendations: an interim set based on the work to date, and a final view once the Case Note Review has reported?
- what were the key themes we would want to reflect in our report?
- how should we engage with NHS GGC in the development of the final report?
PR said there to be an emerging consensus around key themes for recommendations. In the following discussion, the OB concurred with this view.
The Chair agreed that the OB should reconvene to consider its reports.
A.O.B and date of next meeting
The OB agreed to work on reports building on today’s discussions and other reports. It was agreed the next meeting would take place in October.