Poor cleaning, unfit toilets and inadequate staffing all contributed to a potentially lethal superbug outbreak at a hospital, a health board report revealed.
Two surgical wards were closed at Raigmore Hospital in Inverness in January after eight patients were diagnosed with Clostridium difficile (C.Diff) and there was a second outbreak in March.
It has also emerged the same bug was a factor in the death of a patient being treated at another Highland hospital a month later.
The report, to go before NHS Highland's board on Tuesday, June 5, reveals that four of the eight patients infected in January were not immediately isolated due to a lack of available single rooms.
Now actions to prevent a further outbreak of the superbug have been put in place and are set to be complete by the end of August.
A total of 16 recommendations have been made which include revising current NHS Highland guidance on infection control and prevention.
Highland politicians have described the report's revelations as "shocking".
Mary Scanlon, Highlands and Islands Conservative MSP, said: "It would be disappointing if it only highlighted one issue. The fact that it highlights a number of issues is quite shocking.
"I'm just sorry that we have had to see repeated outbreaks before a thorough investigation was carried out. Having highlighted the causes of C.diff in these particular wards, I hope NHS Highland will now look at all wards in Raigmore and all hospitals in the Highland area to ensure that they meet the required standards."
Highlands and Islands MSP Rhoda Grant said the health board's tight budget meant it could not provide en-suite facilities for all patients.
She added: "However poor levels of cleanliness are unforgivable and they need to have sufficient staffing levels to ensure that a hospital is safe.
"It is particularly worrying that under-staffing had previously been flagged up as a problem and nothing was done about it."
The board's infection control executive Heidi May said that domestic staffing levels met national guidelines, but added: "This did not allow for a uniformly first-class standard of cleaning," and there were "shortcomings in the service provided".
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