Cabinet Secretary for Health and Well-being Nicola Sturgeon
Statement following publication of Independent Review and Health Protection Scotland (HPS) report into Clostridium Difficile (C.diff )
August 7, 2008 in Glasgow
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Today sees the publication of the report of the Independent Review Team I commissioned to examine cases of clostridium difficile at the Vale of Leven hospital earlier this year, and the report from Health Protection Scotland concerning the extent of C.difficile across NHS Scotland over the same six month period.
Before turning to the detail of the reports and my response to them, I want to express my sincere and heartfelt condolences to the families of those who died as a result of infection at the Vale of Leven. Many of them have contributed openly and constructively to the work of the Independent Review Team - based on a desire to ensure the quality and safety of care in the future. It was my privilege to meet some of the families earlier today. For me, their messages stand out - and I want to assure them publicly that we are listening and acting on what they tell us.
I wish to record my appreciation to Professor Smith who led the Independent Review Team, and to his colleagues Professor Henry and Dr Philips. The review team's purpose was to look at the circumstances surrounding the outbreak, and to identify areas for improvement. The report makes for challenging and, I have to say, disturbing reading. I accept the findings and recommendations in their entirety and will ensure the actions set out in the report are turned into practical reality without delay. I wish to note too, the contribution of Health Protection Scotland for their analysis of the six month look back exercise on C.difficile by NHS Boards. Their report provides a wider Scottish context, and underlines the importance of effective local surveillance.
I turn now to the findings in relation to the Vale of Leven hospital and NHS Greater Glasgow and Clyde. The independent report confirms that 55 patients contracted c-difficile between December last year and June this year. It also confirms that 18 people died, with c-difficile recorded either as the underlying or a contributory cause of death.
The HPS report shows that the number of cases found at Vale of Leven during that period were not statistically higher than the rest of Scotland. However, as the Independent Review Team report makes clear, local retrospective data supplied by NHS Greater Glasgow and Clyde indicate that there were excesses of cases in January, February and May 2008 when compared with the hospital's own previous patterns of infection. These peaks should have triggered action but there was not an effective local surveillance system in place. As a result, although the cases were all individually identified, the fact that there were more than normal was not.
The independent report and the HPS report also confirm that the number of deaths at Vale of Leven directly attributed to C.difficile was significantly higher than the national average. The factors behind that are complex but include the presence of the 027 strain, the demographics and co-morbidities of patients treated at the Vale of Leven and the state of facilities and infection control procedures at the hospital.
With regard to the state of facilities and procedures at the Vale of Leven, let me be clear that the picture painted by the review team report is appalling and completely unacceptable.
As the report makes clear, it is a picture of a hospital suffering the consequences of 10 years of uncertainty about its future.
It identifies a lack of clear focus and leadership in relation to infection control, a poor standard of physical fabric in the hospital, with inadequate hand hygiene and patient isolation facilities, beds placed too close together, and a shabby appearance even where cleaning was of a high standard. This was compounded by poor staff morale and deficiencies in knowledge and training around infection control in general and C.difficile in particular.
The absence of clear lines of professional responsibility has fostered an environment where there was inadequate management of clusters of cases at ward level, or awareness of problems at higher levels. As I have already indicated, the lack of adequate local surveillance systems led to an excess of cases being missed until a retrospective review was undertaken.
There were also inadequacies and inconsistencies in advice to relatives and in management of patients.
I have this morning apologised to families on behalf of the NHS for what they have gone through.
However, there is no doubt that NHS GG&C also owe the patients and families concerned a direct and unconditional apology for the serious failings on its part that have been identified by the review team. I expect the Board to ensure that they get it.
NHS Greater Glasgow and Clyde has, since the situation at the Vale of Leven came to light, carried out a review of its arrangements at the hospital.
However, I want to make clear today that I expect the Board of NHS Greater Glasgow and Clyde to provide assurances to the populations they serve that their actions will address all of the findings and recommendations of the Independent Review Team.
In particular, I expect to see action:
- Firstly, to strengthen the arrangements for governance, accountability, leadership and performance management, with clear links from the ward and patient care to Board level. I expect to see an explicit and significant reinforcement of clinical leadership and accountability at all levels from senior management to the charge nurse. I expect the Board to ensure that charge nurses are empowered and given appropriate support to enable them to deliver against their responsibilities and I expect the Senior Charge Nurse Review recommendations which I launched in June to be implemented without delay at the Vale of Leven. Medical leadership at all levels in the organisation must also be visible and support the delivery of safe and effective care;
- Secondly, I expect action to implement and monitor best practice - I expect the Board to ensure that arrangements are in place to ensure that good practice with regard to surveillance and infection control becomes the norm; that there is improved communication with patients and relatives; and there are appropriate opportunities for staff training.
I also want to be clear today that I expect the Board of GG&C to make a clear and unequivocal commitment to the future of the Vale of Leven hospital and the sustainability of its services. It is time for the nature of the debate about the Vale of Leven to change. It must no longer be one about what services are to be withdrawn, but instead become one about what action is needed to create a modern, fit for purpose hospital for the future. I have therefore instructed the Board to bring forward a strategy to secure the hospital's future backed by an investment programme to deal with outstanding maintenance and modernisation issue and ensure a safe environment.
The review team has recommended that an external and independent audit of the implementation of all of its recommendations is conducted by the end of this year and that patient representatives are included on the review team for that purpose. That will happen and I have also asked the families to be represented on the review team when it undertakes that work.
Finally in relation to the Vale of Leven let me confirm, in response to the call of some of the families for a full public inquiry that I have passed the review team report to the Lord Advocate who has asked the Area Procurator Fiscal for Argyll and Clyde to consider whether further action should be taken.
I turn now to the wider findings of the HPS report which assessed the extent of c-difficile across all of Scotland's acute hospitals in the period from December 2007 to June 2008.
The report found that there were no clusters or outbreaks of c-difficile that had not been identified, notified as appropriate and acted upon at the time.
With the exception of the Vale of Leven and Woodend hospital in Aberdeen - the latter of which is subject to further investigation - there were also no hospitals with above average deaths from c-difficile.
However, notwithstanding those reassuring findings, it is still the case that the extent of c-difficile is unacceptable. The report identified 3174 cases in the period in question, including 86 deaths where c-difficile was the underlying cause of death and 199 deaths where it was noted on the death certificate as a contributory factor.
I am therefore publishing today an action plan to supplement the work already being taken forward by the HAI Task Force. I have charged the Chief Nursing Officer as chair of the Task Force to ensure that these actions are taken forward speedily and efficiently.
A great deal of work is already underway, but there are areas where I believe further action is needed.
First, there must be far greater emphasis on the development of standardised local surveillance which is robust, sensitive and reliable in identifying excess cases which require further investigation. This will form part of the new C.difficile guidance portfolio being produced by HPS at the end of September.
Second, I am not satisfied that members of NHS Boards have sufficient opportunities to consider, in light of information about infection in their hospitals, the actions required to prevent and manage healthcare associated infections in their areas. To this end I will require all NHS Boards to receive regular reports - against a standard national template developed by the HAI Taskforce and the Scottish Patient Safety Programme - at their public board meetings.
Thirdly, the crucial issue of antimicrobial prescribing and management must be progressed through the Scottish Antimicrobial Action Plan and the best practice guidance issued to NHS Boards. All Boards must have in place an Antimicrobial Management Team and a further half a million pounds is being made available to support the appointment of specialist antimicrobial pharmacists in every NHS Board.
Fourthly, I am determined that appropriate hand hygiene continues to improve in all of our hospitals and healthcare settings and I intend to develop a zero tolerance approach in NHS Scotland to non-compliance.
Other practical measures where I expect to see prompt action include a new dress code which aims to protect patients and staff, and promote public confidence; and guidance on dealing with patients' personal laundry at home - issues raised explicitly by the families at the Vale of Leven.
We will also take steps to extend the mandatory surveillance of c-difficile to under 65s.
It is these actions that will build on the lessons from the Vale of Leven, from the messages from the families, and from the experts, and ensure improved performance for the future.
The publication of these reports today renews my determination to ensure a robust approach to infection at all levels of the NHS in order that C.difficile and other healthcare associated infections are prevented and controlled. This is a key element of our focus on good quality, patient focused care.