Royal Hospital for Children and Young People and Department of Clinical Neurosciences: review of water, ventilation, drainage and plumbing systems - supplementary report

This report supplements the NHS National Services Scotland (NSS) report issued on 9 September 2019 and focuses on the provision of the fire, electrical services and medical gas systems.

1. Executive Summary

1.1 Overview

This document is supplementary to the NSS report issued on 9th September 2019. The objectives of this part of the review were to focus on the provision of the fire, electrical services and medical gas systems at RHCYP & DCN and: 

  • To provide a report by October 2019 to Scottish Government on whether the relevant technical specifications and guidance applicable to the RHCYP & DCN are being followed and implemented.
  • Where relevant technical specifications and guidance have not been followed, identify necessary remedial actions.

This part of the report deals mainly with engineering aspects and there is limited commentary on Healthcare Associated Infection (HAI) associated with these three disciplines as there is little or no impact on HAI from the services considered. The process involved site visits, sample inspections and a targeted review of available documentation.

The review commenced on the 12th of August 2019, with this supplementary report published for consideration by the established RHCYP & DCN Oversight Board.

1.2 Summary of findings 

The findings have been collated based on information provided by NHS Lothian and on-site reviews of the RHCYP & DCN. Expert advice was sought within the key focus areas of Fire, Electrical and Medical Gas systems and their overarching management and assurance processes relating to these systems. The following table outlines the status of key findings:


Summary Assessment

No. of Issues per priority

1 (H)




5 (L)

Management & Assurance

Omissions identified in key roles within the management structure, ease of access to information and possible lack of appropriately qualified personnel in safety critical roles.






Fire systems

Action is recommended to include remotely resettable fire and smoke dampers within the ventilation system serving all sleeping accommodation areas where ducting leads to a corridor serving as an evacuation route. Identified fire doors should be upgraded.





Electrical Systems 

Remedial action is required within both the high voltage (HV) and low voltage (LV) installations.





Medical gas systems

The review of the medical gas installations confirmed that they have been designed installed and commissioned in accordance with the relevant standards.






The following definitions were used to categorise the findings: 




Significant – Concerns requiring immediate attention, no adherence with guidance


Major – Absence of key controls, major deviations from guidance


Moderate – Not all control procedures working effectively, elements of non-compliance with guidance 


Minor – Minor control procedures lacking or improvement identified based on emerging practice


Observation and improvement activity 

Overall remedial action is required to be undertaken within the fire and electrical systems prior to occupation. Observations have been identified within medical gas installations and a further improvement activity within the fire system noted. Following acceptance of this report, the review team are ready to assist the NHS Lothian team in developing a programme of activity and remedial actions.



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