There was a spike in infections at the Royal Children’s Hospital in Glasgow around the time of a ten-year-old girl’s death, according to a report.
The document, published by Health Protection Scotland (HPS), was produced following Milly Main’s death after she contracted an infection as she received leukaemia treatment at the site, which is shared with the Queen Elizabeth University Hospital.
After undergoing a successful stem cell transplant in July 2017, Milly had been making a recovery but the following month her Hickman line, a catheter used to administer drugs, became infected.
Milly then went into toxic shock at the hospital and died some days later.
Her mother, Kimberly Darroch, has thanked the whistleblower who first contacted Scottish Labour MSP Anas Sarwar about the hospital.
She said: “I want to thank the whistleblower for coming forward. As a result of their action, we now have more information about infections at the hospital that we were never told about as a family at the time.
“We didn’t know there was a spike in infections around the time Milly died, which is why we now want answers.
“The silence from the health board must come to an end so that no parent ever has to go through what we have been through.”
The HPS report found there was an upward shift above the infections rate average from March to December 2017, with the upper warning limit breached in August 2017, the month of Milly’s death. It was also breached in March and May 2018, and in September this year.
Different sources of data on positive blood samples among children being treated for cancer in NHS Greater Glasgow and Clyde over a period of years were compared within the report, with statistical analysis highlighting the months in which rates of positive blood samples were higher than would be expected.
Stenotrophomonas maltophilia is one form of gram-negative bacteria that is found in various water environments and was listed on Milly’s death certificate in August 2017.
‘We didn’t know there was a spike in infections around the time Milly died, which is why we now want answers.’Kimberly Darroch, Milly’s mum
It causes problems mainly in people who have a weakened immune system. The report follows a whistle-blower’s claim to have identified ten new cases at the site, suggesting young people could have been falling victim to bugs since 2016.
Two wards at the children’s hospital were closed more than a year ago for work to be carried out after health concerns.
Sarwar said: “This HPS report confirms the information exposed by a brave whistleblower.
“Without them, this scandal may never have come to light.
“There are now clearly a number of serious questions about the above-average infection rates in 2017 and the upper warning limit being breached around the time Milly tragically died.”
He added: “Now that this information has come to light, the health board must urgently explain why this was hidden from the public, whether the parents of all children have been informed, why repeated warnings were ignored and why action wasn’t taken that could have prevented tragedy.
“We now know that the upper limit was again breached as recently as September this year.
“With the health board in special measures, it’s vital that parents, patients and the public receive answers and full transparency.”
The national clinical director for the Scottish Government, Professor Jason Leitch, apologised to the families involved.
He added: “The review by Health Protection Scotland was commissioned by the Chief Nursing Officer in September to determine if the numbers of positive blood samples for infections among child cancer patients were higher than expected.
“The report identifies months in which rates of infection exceeded the trigger point requiring further investigation.
“These data confirm there was a spike in infections in 2018 – this led to the interventions over water contamination and the closure of wards 2A and 2B.
“These data also confirm higher levels of infections in 2017 and these incidents are part of the reason the Scottish Government announced last week that the board has been elevated to stage four of the NHS Board Performance Escalation Framework.
“This means a Scottish Government-led oversight board will help strengthen the measures already in place around infection prevention, management and control.
“It will also ensure the recommendations of this report are actioned.
“The present infection rate at the children’s hospital is normal and the cancer ward is safe.”