5. Technical Review
163. Given the prominence of the physical environment in responding to and understanding the infection incidents, the Health Board's systems of assurance, particularly around water safety, are critical. The Technical Issues Subgroup focused on these technical issues of assurance. In the Interim Report, an update was given on progress on the refurbishment and reopening of Wards 2A and 2B in the RHC, following its closure in September 2018. The Final Report focuses on the following remaining issues:
- NHS GGC's water safety policy, with specific attention given to its water testing regime and how testing results are being used as part of IPC and the key water and ventilation infrastructure in light of the infections across the hospital site; and
- NHS GGC's plans to monitor infrastructure improvements required in response to the issues around the building of the hospital as well as the impact of the chemical dosing system introduced from late 2018 to address water system contamination.
5.1 Review of Water Safety Policy
164. Water safety policy in NHS GGC is governed by a Board-wide policy document, with specific issues covered in a written scheme for the QEUH site. In particular, the written scheme document outlines the specific roles, responsibilities, training requirements and regular maintenance procedures to be followed in order to ensure compliance with statutory and mandatory guidance. Given the heightened importance of water testing against a backdrop of water contamination issues, the policy has a particular significance in providing assurance of the Health Board's ability to handle outbreaks.
165. At the request of the Oversight Board, HFS reviewed the Health Board's water policy and the NHS GGC QEUH campus water systems written scheme. This involved reviewing Health Board documents against national guidance and expectations including:
- SHTM 04-01;
- HSE ACOP L8;
- HGS 274 Part 2;
- BS 7592:2008 Sampling for Legionella bacteria in water systems. Code of practice;
- BS 8580-1:2019 Water quality. Risk assessments for Legionella control. Code of practice; and
- BS 8680:2020 – Water Quality – Water Safety Plans – Code of Practice.
166. HFS concluded that the documents set out a sufficient and appropriate description of the water policy. A number of areas for further improvement were suggested for the two key documents – the water safety policy and the QEUH written scheme – to add resilience.
- For the QEUH written scheme:
- point-of-use filter installation and management was not identified, and should be enhanced given the heightened maintenance needs around this in the QEUH;
- there should be clear patient cohort susceptibility and risk assessments relating to various organisms, particularly environmental ones, to demonstrate that there is a clear recognition of addressing the vulnerability of certain patient groups, given the water contamination risks: those risk assessments should be explicitly referenced (and summarised where useful) and a process for triggering and considering such risk assessments in future should be included in the scheme;
- a chlorine dioxide management and strategy was not identified – the whole-site dosing system brings additional infrastructure and maintenance issues for the Health Boards which need to be explicitly acknowledged;
- dental, hydrotherapy and scalding risks should be detailed as appropriate; and
- it would be prudent to update the formatting of the documents to reflect recent changes, such as BS 7592, BS 8580 and BS 8680 (2020).
- For the water policy: the Health Board should consider a shorter policy document with all detail placed in the QEUH written scheme.
- It is also recommended that there is explicit reference in the documents to who interprets the testing results. From the Facilities and Estates perspective, the renewed focus on the use of Authorised Persons is welcomed, and this would be strengthened with clear links to microbiologists – especially ICDs – in the formal and systematic consideration of results for the site.
167. Sampling procedures are explicitly set out in accompanying documents. Gram-negative bacteria are checked at different frequencies throughout the QEUH, but in targeted locations. For example, regular samples have been carried out in Ward 6A in the QEUH since December 2019, including Pseudomonas and a variety of Gram-negative bacteria; a quarter of outlets are sampled weekly on a rotational basis so the whole ward is covered each month. This would also appear to be proportionate.
168. The governance around flagging any 'out of specification' results should be strengthened. There should be a clearly expressed route for raising these results within the IPC governance structures and relevant committees having explicit oversight of high-TVC results with accompanying advice from appropriate Facilities and Estates, IPC and microbiologists presented for consideration.
169. However, the Oversight Board also notes the criticisms of water sampling and testing practice identified in the Case Note Review, particularly in how environmental results were used to support IPC. As recommended in its Overview Report:
"A systematic, fit for purpose, routine, microbiological water sampling and testing system is required to provide assurance going forwards. How the results from such sampling/testing are recorded, accessible and used to highlight concerns should be reviewed, including to ensure that investigations of possible links between clinical isolates and water/environment sources can be informed in a timely way."
5.2 Plans for Infrastructure Review
170. An enhanced approach to infrastructure maintenance, particularly with respect to water systems, is an inevitable expectation of the Health Board against a context of continuing problems with the building. The site-wide chemical dosing system introduces new maintenance challenges, while the Independent Review set out a number of recommendations which had implications for remedial work on the building. Assurance that actions are being taken to address the identified problems and risks and monitor them going forward is an important consideration for the Oversight Board.
171. With respect to the Independent Review, a detailed action plan is currently being developed in accordance with the methodology set out in the NHS Scotland 'Improvement Focused Governance' guidance document. Each action has a nominated lead executive. The NHS GGC Gold Command Steering Group, 'Better Every Day', will review, monitor and report progress against the action plan to the executive management team and onward to the Finance Planning and Performance Committee.
172. One other issue that the Oversight Board specifically considered was the programme for addressing water taps across the hospital. At the height of the 'water incident' in 2018, it was recognised that taps and flow straighteners were harbouring biofilm and work commenced on swapping the Horne taps with an alternative. However this was halted following the chemical dosing system's installation. Further to the introduction of chlorine dioxide it was demonstrably evident that biofilm was no longer within the flow straightener. This issue will remain under constant review by the Water Technical Group. It has been agreed, however, that during any future upgrading works that the Marwick taps will be installed.
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