Vale of Leven C.Diff inquiry reveals systemic failures

The Vale of Leven Hospital Inquiry has revealed that serious personal and systemic failures contributed  to the deaths of 34 patients from Clostridium difficile infection (CDI).

The Inquiry, chaired  by the Rt Hon Lord MacLean, found that 143 patients tested positive for CDI at Vale of Leven Hospital during the period  January  2007 to 31 December  2008.  CDI  was a factor in the death of 34 of those patients.

Unveiling the report today (Monday 24th November 2014) at  Fifteen  Ninety Nine ( the premises of the  Royal College of Physicians and Surgeons of Glasgow), Lord MacLean 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. There were failures by individuals but the overall responsibility has to rest  with the Health Board.

“The Scottish Ministers bear ultimate responsibility for NHS Scotland and, even at the level of the Scottish Government, systems were simply not adequate to tackle effectively a healthcare associated infection like CDI.

“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 expresses his view that the figure of 34 deaths is probably an underestimate as medical records were not available for all of the patients during the period in question.

The Inquiry Report identifies a number of failings

• Governance and management failures within NHS Greater Glasgow and Clyde which created an environment in which patient care was compromised and infection prevention and control was inadequate
• Inadequate attention given by NHS Greater Glasgow and Clyde and the Scottish Government agencies to reports about other CDI outbreaks in the UK which identified failures similar to many of those at Vale of Leven Hospital
• Significant deficiencies in infection prevention and control practices and systems which had a profound impact on the care provided to patients in the hospital
• Deficiencies in nursing care and medical care which seriously compromised the care of patients
• Uncertainty over the Hospital’s future which had damaging effects on recruitment, staff morale and the hospital environment
• Lack of strong management which contributed to a culture unsuited to a caring and compassionate hospital environment

Lord MacLean pays tribute in his report to the important contribution made to the Inquiry by patients and relatives and to the work of the C.diff Justice Group which represents a number of surviving and deceased patients.

There are 75 recommendations in  the report including recommendations on infection prevention and control, nursing and medical care, antibiotic prescribing, communication with patients and relatives, and death certification. Lord MacLean comments:

“My recommendations are designed to encapsulate patient care that includes skilled and considerate medical and nursing care, transparency, candour, effective systems of infection prevention and control, and strong and dedicated leadership.

“Aspects of basic nursing care such as fluid monitoring, care planning, and prevention and management of pressure damage are integral to good quality care. I make no apology for including recommendations on these issues to reinforce how critical they are.

“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. 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 acknowledges that some of the report’s recommendations may have been overtaken by events. He says: “NHS Greater Glasgow and Clyde did introduce more effective reporting systems for CDI after June 2008 but the message should be reinforced that systems must ensure that important information is relayed from ward to Board.

“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.”

The Inquiry, in accordance with the Inquiries Act 2005, was inquisitorial in nature and not adversarial. It had no power to determine civil or criminal liability.

A full copy of the Inquiry report including an executive summary is available on the Inquiry website at www.valeoflevenhospitalinquiry.org