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| Vale of Leven C. diff inquiry criticises health board | Vale of Leven C. diff inquiry criticises health board |
| (about 1 hour later) | |
| Scotland's largest health board has been heavily criticised by an inquiry into the country's worst Clostridium difficile (C. diff) outbreak. | Scotland's largest health board has been heavily criticised by an inquiry into the country's worst Clostridium difficile (C. diff) outbreak. |
| The probe, led by Lord MacLean, looked into care at Dunbartonshire's Vale of Leven Hospital between 2007 and 2008. | |
| Of the 143 patients with C. diff, it was a contributory factor in 34 deaths. | Of the 143 patients with C. diff, it was a contributory factor in 34 deaths. |
| Lord MacLean said NHS Greater Glasgow and Clyde (GGC) had "badly let down" patients. The health board apologised unreservedly for a "terrible failure". | |
| The judge said: "The inquiry has discovered serious personal and systemic failures. | The judge said: "The inquiry has discovered serious personal and systemic failures. |
| "Patients at the Vale of Leven Hospital were badly let down by people at different levels of NHS Greater Glasgow and Clyde who were supposed to care for them." | "Patients at the Vale of Leven Hospital were badly let down by people at different levels of NHS Greater Glasgow and Clyde who were supposed to care for them." |
| 'Personal suffering' | |
| He added: "There were failures by individuals but the overall responsibility has to rest with the health board." | He added: "There were failures by individuals but the overall responsibility has to rest with the health board." |
| Lord MacLean said "systems were simply not adequate to tackle effectively a healthcare associated infection" like C. diff. | Lord MacLean said "systems were simply not adequate to tackle effectively a healthcare associated infection" like C. diff. |
| He added: "The major lesson to be learned is that what happened at Vale of Leven Hospital to cause such personal suffering should never be allowed to happen again." | He added: "The major lesson to be learned is that what happened at Vale of Leven Hospital to cause such personal suffering should never be allowed to happen again." |
| Lord MacLean also expressed his view that the figure of 34 deaths was probably an underestimate as medical records were not available for all of the patients during the period in question. | Lord MacLean also expressed his view that the figure of 34 deaths was probably an underestimate as medical records were not available for all of the patients during the period in question. |
| He cited poor facilities, such as a lack of wash hand basins and a lack of commodes, as well as issues with the fabric of the building as evidence of poor management. | He cited poor facilities, such as a lack of wash hand basins and a lack of commodes, as well as issues with the fabric of the building as evidence of poor management. |
| The judge said that prolonged uncertainty over the future of the Vale of Leven hospital contributed to poor morale and recruitment. | The judge said that prolonged uncertainty over the future of the Vale of Leven hospital contributed to poor morale and recruitment. |
| Management failures | Management failures |
| Poor leadership among NHS GGC managers, the judge said, contributed to substandard nursing care and deficiencies in medical staffing. | Poor leadership among NHS GGC managers, the judge said, contributed to substandard nursing care and deficiencies in medical staffing. |
| He said inexperienced junior doctors had too much responsibility and consultants were stretched. | He said inexperienced junior doctors had too much responsibility and consultants were stretched. |
| Lord MacLean also said antibiotics were prescribed in cases where it was inappropriate. | Lord MacLean also said antibiotics were prescribed in cases where it was inappropriate. |
| His report identified a number of failings: | His report identified a number of failings: |
| There are 75 recommendations in his report, including recommendations on infection prevention and control, nursing and medical care, antibiotic prescribing, communication with patients and relatives, and death certification. | There are 75 recommendations in his report, including recommendations on infection prevention and control, nursing and medical care, antibiotic prescribing, communication with patients and relatives, and death certification. |
| 'Repeated warnings' | 'Repeated warnings' |
| Lord MacLean added: "An effective inspection regime, I am convinced, would have been able to identify the dysfunctional nature of infection prevention and control at the hospital. | Lord MacLean added: "An effective inspection regime, I am convinced, would have been able to identify the dysfunctional nature of infection prevention and control at the hospital. |
| "There must be an effective line of reporting, accountability and assurance. | "There must be an effective line of reporting, accountability and assurance. |
| "This was lacking for the Vale of Leven Hospital. In addition, repeated warnings over a number of years about the importance of prudent antibiotic prescribing had no impact." | "This was lacking for the Vale of Leven Hospital. In addition, repeated warnings over a number of years about the importance of prudent antibiotic prescribing had no impact." |
| Lord MacLean acknowledged that improvements had been made since the C. diff outbreak. | Lord MacLean acknowledged that improvements had been made since the C. diff outbreak. |
| He said: "NHS Greater Glasgow and Clyde did introduce more effective reporting systems for CDI (C. diff) after June 2008 but the message should be reinforced that systems must ensure that important information is relayed from ward to board (NHS GGC). | He said: "NHS Greater Glasgow and Clyde did introduce more effective reporting systems for CDI (C. diff) after June 2008 but the message should be reinforced that systems must ensure that important information is relayed from ward to board (NHS GGC). |
| "I am convinced that the adoption of the recommendations proposed will result in a significantly improved focus on patient care, and in particular, care of patients who contract an infection such as CDI. | "I am convinced that the adoption of the recommendations proposed will result in a significantly improved focus on patient care, and in particular, care of patients who contract an infection such as CDI. |
| "Although it was the failures in how CDI was managed at the hospital that governed the work of the inquiry, the recommendations should, I hope, have a more far-reaching impact." | "Although it was the failures in how CDI was managed at the hospital that governed the work of the inquiry, the recommendations should, I hope, have a more far-reaching impact." |
| 'Profound regret' | |
| Andrew Robertson, chairman of NHS GGC, said: "On behalf of the board and our staff, I would like to offer an full and unreserved apology to the patients affected and to the families who lost a relative to C. diff in the months between January 2007 and late 2008. | |
| "This was a terrible failure and we profoundly regret it. | |
| "I can give the firmest of assurances that, as a result of the lessons that have been learned, this could not happen again." | |
| Health board chief executive, Robert Calderwood, added: "Re-iterating my personal apology I hope the relatives can take some comfort that the lessons learned from this outbreak have resulted in significant improvements in clinical practice, for instance, in more prudent prescribing of antibiotics. | |
| "These major improvements introduced since the tragic events of six years ago have made the Vale and all of our hospitals in Greater Glasgow and Clyde safer for patients than they have ever been." |