Royal Hospital for Children and Young People and Department of Clinical Neurosciences: response to the review of water, ventilation, drainage and plumbing systems

NHS Lothian's response to actions identified in NHS National Services Scotland's review of water, ventilation, drainage and plumbing systems in the Royal Hospital for Children and Young People and Department of Neurosciences, Edinburgh.


NSS Review: Remedial action is required within both general and theatre ventilation systems. Augmented care redesign was already being considered separately by the Board. Haematology / Oncology is also being reviewed as a result of the review as specific risks were identified. Risk assessments are underway as part of the ward by ward risk assessments being done locally requested as part of the review.

NHS Lothian response: The required remedial actions are underway with expert input from the engineers. Two Board changes have been progressed for the areas to be redesigned. Discussion with clinical staff and the Infection Prevention and Control Team (IPCT) will guide patient placement in line with documented risk assessments.

Issue NSS Review NSS Action Assessment NHS Lothian action
General ventilation systems 1 Provision for maintenance or plant failure in the ventilation systems has not been validated in accordance with SHTM 03-01 Ventilation for Healthcare Premises. The bypass arrangements and functioning of ward ventilation in the event of plant failure remains to be demonstrated. Demonstrate efficacy of approach of utilising adjacent air handling unit to supply areas not served by failed plant.

Commission and validate isolation rooms and general ward spaces in the event of supply by adjacent air handling unit.

Engage clinical leads and Infection Prevention and Control colleagues in developing service provision strategies in the event of air handling plant failure.

Confirm damper operation and compliance with fire requirements in bypass mode.
The date for the demonstration of bypass arrangements is to be confirmed by 13 September 2019.

Patient safety in the event of a reduction of air exchange, for any reason, will be managed through infection prevention and control guidance and clinical risk assessment.

Work is ongoing with contractors to ensure damper operation is compliant. The programme of works is to be provided by IHSL by 13 September 2019

General ventilation systems 2 Air handling units and ductwork contain numerous deviations from contract requirements (SHTM 03-01) and were found not to be clean despite having been presented for validation. Deviations include: loose internal cabling in the airflow, cable routes allowing air to bypass filters, air leakage at penetrations and possible fan replacement difficulties which need to be corrected. The ventilation systems throughout the hospital should be subject to a full snagging exercise and all defects rectified following which air handling units and ventilation systems are cleaned. All deficiencies identified in validation and specialist Consultant Engineer reports should be addressed as part of this. We are working closely with IHSL to ensure all the issues identified in the reports have been rectified.

A specimen AHU with all the deficiencies rectified will be made available to NHS Lothian for inspection by HFS and our engineers in September 2019.

General ventilation systems 3 The general ward ventilation design is based on four air changes per hour mechanical ventilation plus a component of natural ventilation. With a few exceptions, the mechanical component has been validated. However, design and validation information for the natural component has not been proven. Confirm that all areas served by this arrangement are suitable for categorisation as general ward areas or single rooms as listed in SHTM 03-01 Part a, Appendix 1.

Undertake an IPCT risk assessment ward by ward/ speciality specific in relation to the guidance.
A risk assessment undertaken by IPCT and clinical teams will be completed by 13 September to ensure that patient placement recognises the general ward ventilation provision.
General ventilation systems 4 The pressure regimen detailed in the design, and reflecting the environmental matrix, will be affected by opening windows and the pressure between the room and the corridor, and therefore direction of air flow, cannot be relied upon when windows are open. A full assessment of the services and patient population should be carried out and mechanisms for monitoring established. AGREED
Ward level risk assessments will recognise the contribution of open windows to the ventilation provided mechanically.
General ventilation systems 5 External doors to plant rooms Ensure that excessive gaps are removed and appropriate anti vermin measures are applied to all the doors and screens as per SHTM 03-01 and HFS Interim Guidance - Managing the Risk of Contamination of Ventilation Systems by Fungi from Bird Droppings – February 2019. AGREED
This will be addressed by the end of September. All doors will then comply with the guidance.
General ventilation systems 6 Fire dampers in some locations cannot be adequately tested as duct access has not been provided. Also, locations of fire dampers and fire rated ductwork has been questioned in relation to the requirements of SHTM 03-01 and confirmation of compliant provision is awaited. Provide access so all fire dampers can be readily visually inspected to verify operation. Review fire damper provision and fire rated ductwork and confirm appropriate provision AGREED
Access to fire dampers will be corrected as part of the work to air handling units.
General ventilation systems 7 Air intake location - Air intakes and opening windows are sited in the courtyard below the helipad and at the adjacent RIE. Information has not been provided on the impact of downdraft on air flows and pressures or entrainment of contaminants as per SHTM 03- 01. Demonstrate the effect of helicopter landing on air flows in ventilation systems with intakes below through measurement when test flights take place or through modelling. This should include the air intakes of the RIE adjacent. Modelling information has been shared with NSS. The effects of test flights on air flows will be measured in September/ October 2019.
Theatre ventilation systems 1 Scrub areas which are narrow and deep are unlikely to be scavenged effectively by theatre air changes and require e alternative means of achieving removal of contaminants as per SHTM 03-01. The efficacy of the high level extract to achieve sufficient dilution of contaminants or entrainment of heavier than air water droplets is not in accordance with the requirements of SHTM 03-01and has not demonstrated as equivalent. The ability of the single high level extract provided in deep plan scrub areas to effectively prevent contaminants being dispersed into theatres should be demonstrated and/or additional low level ventilation provided. AGREED
Evidence to confirm the adequate dispersal of contaminants has been requested. If this not satisfactory then a Board change will be instructed to provide low level ventilation.
Theatre ventilation systems 2 Anaesthetic rooms 31 and 34 do not demonstrate a clean air flow path to reduce exposure of staff to gasses as per SHTM 03-01. Move ceiling supply to opposite side of room from extract. In room 30, move supply away from door. Move ceiling supply to opposite side of room from extract. In room 30, move supply away from door. Demonstration of a clean air path has been requested by 13 September 2019; otherwise the supply will be moved.
Theatre ventilation systems 3 Theatre utility rooms Extract ventilation means theatres have to be used in pairs and taking a theatre out of service may reduce the extract in utility room below the levels as per SHTM 03-01. Add supplementary extract ventilation to allow for one theatre being out of service or plan for service impact following the loss of a pair of theatres.

NHS Lothian has advised that the appropriate pressure differentials are maintained when only one theatre is operation. Validation evidence is to be provided.
IHSL have provided evidence that this arrangement meets the standard. Final checks on this are being completed.
Isolation room ventilations systems Isolation rooms are not served by a single ventilation system for each room as recommended in SHPN4 Supplement 1. The arrangement provided, where ventilation systems serve an area of the building including contained isolation rooms, has not yet been proven in the event of failure of an air handling unit and the implications for service impact are not yet understood. Prove that bypass connections to adjacent ventilation systems will allow safe operation of both areas and / or explain service provision strategy for loss of each area including isolation rooms. Also include assurance on operational effectiveness e.g. the pressure differentials and air flows being maintained.

Develop clinical service provision strategy to reflect the potential loss of up to 5 of the 19 isolation rooms on the failure of an air handling unit and confirm impact on service continuity.
The date for the demonstration of bypass arrangements is to be confirmed by 13 September 2019.

Detailed advice from the infection control team to allow bespoke risk assessments would be followed in such circumstances.



Back to top