Summary: Full List of Recommendations
This Final Report sets out the findings and recommendations of the NHS Greater Glasgow and Clyde (GGC) Oversight Board's programme of work in response to the infection issues affecting the Queen Elizabeth University Hospital (QEUH) and the Royal Hospital for Children between 2015 and 2019. It summarises the work on investigation, dialogue and improvement driven by the Oversight Board since its establishment in December 2019 through to March 2021.
The Oversight Board was established by the Director-General of Health and Social Care in the Scottish Government and Chief Executive of NHS Scotland in November 2019. This decision was taken in response to critical issues relating to the operation of infection prevention and control, governance, and communication and engagement with respect to the Queen Elizabeth University Hospital and the handling of infection incidents affecting children, young people and their families within the paediatric haemato-oncology service. The appointment of an Oversight Board was a direct consequence of the escalation of the Health Board to Stage 4 of NHS Scotland's national performance framework.
The Oversight Board consists of a group of experts and representatives drawn from other Health Boards, the Scottish Government and the affected families themselves. Chaired by Scotland's Chief Nursing Officer, Professor Fiona McQueen, the work of the Board was carried out principally through three Subgroups: Infection Prevention and Control and Governance; Technical Issues; and Communication and Engagement. Overall, the Oversight Board has focused on assurance of current systems and reviewing the historical issues that gave rise to escalation, essentially through a focus on a set of overarching questions:
- To what extent can the source of the infections be linked to the environment and what is the current environmental risk?
- Are infection prevention and control (IPC) functions 'fit for purpose' in NHS GGC, not least in light of any environmental risks?
- Is the governance and risk management structure in NHS GGC adequate to pick up and address infection risks?
- Has communication and engagement by NHS GGC been sufficient in addressing the needs of the children, young people and families with a continuing relationship with the Health Board in the context of the infection incidents?
In addition, an independent Case Note Review was commissioned to examine the individual incidents of infection among the children and young people. This review is being overseen by an Expert Panel that is reporting separately but at the same time as the Oversight Board. Its findings have informed this Final Report.
Infection Prevention and Control
The Interim Report covered the following selected areas of Infection Prevention and Control (IPC):
- the degree to which specific IPC processes in the QEUH have been aligned with national standards and good practice; and
- the extent to which the IPC Team has demonstrated a sustained commitment to improvement in infection management across the Health Board.
These recommendations are set out below.
The Final Report makes further findings and recommendations for the remaining IPC issues, particularly: IPC governance; the responsiveness of the Health Board's IPC to the infection incidents; the effectiveness of joint working in support of IPC in the QEUH; and the strength and organisation of leadership in IPC.
- With the support of ARHAI Scotland and Healthcare Improvement Scotland, NHS GGC should undertake a wide-ranging benchmarking of key IPC processes through a more comprehensive Peer Review exercise. Particular attention should be given to the approach to IPC audits, surveillance and the use of Healthcare Infection Incident Assessment Tools (HIIATs).
- With the support of ARHAI Scotland, NHS GGC should review its local translation of national guidance (especially the National Infection Prevention and Control Manual) and its set of Standard Operating Procedures to avoid any confusion about the clarity and primacy of national standards.
- With the support of Health Facilities Scotland, NHS GGC should undertake a review of current Healthcare Associated Infection Systems for Controlling Risk in the Build Environment (HAI-SCRIBE) practice to ensure conformity with relevant national guidance.
- A NHS GGC-wide improvement collaborative for IPC should be taken forward that prioritises addressing environmental infection risks and ensuring that IPC is less siloed across the Health Board.
- Strengthened arrangements for IPC, commensurate with the complexity and size of the Health Board, should be put in place in line with relevant national guidelines.
- The structure of IPC should reflect the continuing need to address the complex and continuing issues within the QEUH. IPC resourcing and skills should be reviewed, and active consideration given to whether there should be appointment of specific IPC roles with QEUH responsibility.
- NHS GGC should ensure that there is a full, effective and standardised approach to the relevant microbiological, water testing and other information regarding the QEUH outbreaks. Relevant data should be integrated in a way that allows effective collecting, recording and analysis of information relating to the incidents, which will be reported through the IPC governance system.
- Building on work already in place, there should be further visible and systematic planning for strengthening coordination between IPC and Facilities and Estates, particularly with respect to forward planning in addressing continuing infection risks with the QEUH and specifically in relation to water testing.
- ARHAI Scotland should review the National Infection Prevention and Control Manual in light of the QEUH infection incidents.
- Health Facilities Scotland should lead a programme of work to provide greater consistency and good practice across all Health Boards with respect to the use of HAI-SCRIBE.
- ARHAI Scotland should review the existing national surveillance programme with a view to ensuring there is a sustained programme of quality improvement training for IPC Teams in each Health Board, not least with respect to surveillance and environmental infection issues.
- ARHAI Scotland should lead on work to develop clearer guidance and practice on how HIIAT assessments should be undertaken for the whole of NHS Scotland.
- ARHAI Scotland should lead in developing and implementing a research programme to address any current gaps in the understanding of environmental infections and how hospitals can address them.
- There are a number of existing national recommendations that were made in the 2018 Health Protection Scotland report that have yet to be fully implemented. ARHAI Scotland should provide an update and timebound action plan for implementing these.
- IMTs in NHS GGC should be more rigorous in developing and making accessible key documentation to support records and analyses of a series of outbreaks over a prolonged period. This should be implemented by NHS GGC, with support from ARHAI Scotland who can identify best practice and make changes to national guidance if this is required.
- Where there are a number of successive infection incidents in the same or a related location, NHS GGC should work with ARHAI Scotland to pilot a process that goes beyond the current IMT focus on individual incidents on behalf of NHS Scotland.
Governance and Risk Management
To address one of its key questions – is the governance structure in NHS GGC adequate to pick up and address infection risks? – the Oversight Board considered how infection management and risk was addressed by NHS GGC. This included reviewing: the framework for governance around IPC; how that system was implemented over the period; and how the risks around these infection incidents were identified, assessed and managed.
- The Health Board should finalise and implement its IPC Assurance and Accountability Framework.
- A review should be undertaken of how the environmental risk of significant water contamination within the QEUH is being assessed and managed in the Health Board's approach to risk management, and changes made to relevant risk registers and risk management planning as a result.
- The Health Board should set out a clearer, more targeted focus on the corporate risk process.
- The Health Board should review how concerns raised about environmental risks are communicated to senior Committees and the Board, and the procedures to ensure that such concerns are addressed. Moreover, it should also ensure the responses are communicated appropriately to those raising concerns.
- The experience of NHS GGC in addressing the unique challenges of the QEUH should be systematically used to shape NHS Assure as early as possible. This should be part of a comprehensive process of developing a template for a 'ward-through-Board' governance system that ensures risks of this nature are appropriately escalated and de-escalated.
Communication and Engagement
Recommendations are set out below with respect to the overarching question considered by the Oversight Board: has communication and engagement by NHS GGC been sufficient to address the needs of the children, young people and families with a continuing relationship with the Health Board in the context of the infection incidents? The recommendations from the Interim Report are presented in blue.
- NHS GGC should pursue more active and open transparency by reviewing how it has engaged with the children, young people and families affected by the incidents, in line with the person-centred principles of its communication strategies. That review should include close involvement of the patients and families themselves.
- NHS GGC should ensure that the recommendations and learning set out in this report should inform an updating of the Healthcare Associated Infection Communications Strategy and an accompanying work programme for the Health Board.
- NHS GGC should make sure that there is a systematic, collaborative and consultative approach in place for taking forward communication and engagement with patients and families. Co-production should be pursued in learning from the experience of these infection incidents.
- NHS GGC should embed the value of early, visible and decisive senior leadership in its communication and engagement efforts and, in so doing, more clearly demonstrate a leadership narrative that reflects this strategic intent.
- NHS GGC should review and take action to ensure that staff can be open about what is happening and discuss patient safety events promptly, fully and compassionately.
- Given that organisational duty of candour was considered, but not formally activated, NHS GGC should review its approach to ensure that it is not simply focused on patient safety incidents and circumstances where causality is clear. There should be greater consideration of the duty where events could result in death or harm. There should also be improved guidance on how the Health Board will balance with other duties perceived as barriers to meeting the organisational duty of candour obligations.
- The experience of NHS GGC should inform how all of NHS Scotland can improve communication with patients and families 'outside' hospitals in relation to infection incidents.
- The experience of NHS GGC in systematically eliciting and acting on people's personal preferences, needs and wishes as part of the management of communication in these infection incidents should be shared more widely across NHS Scotland.
- NHS GGC should learn from other Health Boards' good practice in addressing the demand for speedier communication in a quickly-developing and social media context. The issue should be considered further across NHS Scotland as a point of national learning.
- The Scottish Government, with Healthcare Improvement Scotland and ARHAI Scotland, should review the external support for communication to Health Boards facing similar intensive media events.
- The findings of the Oversight Board in respect of the application of the organisational duty of candour in NHS GGC should be considered by the Scottish Government and Healthcare Improvement Scotland in order that further implementation support and guidance can be developed around the issues noted.
- The Health Board should expedite the refurbishment of Wards 2A and 2B in the RHC as safely and quickly as possible, and keep affected children, young people and families fully informed of the developments.
- A programme of testing and review should be put in place to assess any potential impacts of the chemical dosing water solution on infrastructure.
- The various action plans and reviews attached to these recommendations should be compiled into a single response to the Oversight Board, and implementation overseen by NHS GGC and the Scottish Government.