A health board has apologised to families after an interim report into infection issues found failings at one of Scotland’s newest hospitals.
The Queen Elizabeth University Hospital Oversight Board was set up to address the specific issues of infection prevention and control at the £842m facility, which opened in 2015.
A separate independent review was ordered by health secretary Jeane Freeman following the deaths of three patients between December 2018 and February 2019.
An adult and a child died after they contracted cryptococcus, an infection linked to pigeon droppings.
Milly Main, ten, died in 2017 at the hospital from an infection, which her mother said she believes was “100%” due to contaminated water.
The oversight board said it recognised that there were “significant shortcomings” in the construction and handover of the QEUH, and how NHS Greater Glasgow and Clyde (NHSGGC) responded to emerging and related problems.
It said these “include the concerns that were raised by a number of clinicians at an early stage as well as how ‘warning signals’ about potential problems were – or were not – acted upon over the years”.
The report said some of the clinicians did not feel that their concerns – particularly about water and ventilation and the risk of their contribution to infection of such a vulnerable patient population – were being effectively addressed.
The independent review, published in June, found no sound evidence avoidable deaths resulted from failures in the design, build, commissioning or maintenance of the QEUH and Royal Hospital for Children (RHC) which is part of the campus, but said certain aspects of the design, build, commissioning and maintenance of the flagship hospital have increased the risk of infections.
The interim report published on Monday highlighted dissatisfaction among parents about communication with NHSGGC, which was placed in level-four special measures by the Scottish Government last year amid the ongoing concerns.
Wards 2A and 2B at RHC were closed in September 2018 after contamination was found in water outlets and drains in 2A, and children were moved to wards in the main QEUH building.
The report said there had been “a clear failure of the goals of communication” for this group of children and their families, with suggestions patients and families were hearing about key information through the media and health board press releases, rather than directly, adding to an impression of too often being “kept in the dark”.
The report made 17 recommendations including that the health board should pursue “more active and open transparency”.
Jane Grant, NHSGGC chief executive, said: “The report covers what has been a very difficult period for our patients, their families and our staff and I would once again say how sorry we are for the distress caused to families affected.
“The findings highlight several areas of learning for NHSGGC. We are fully committed to applying those lessons from this experience.
“We welcome the areas of good practice highlighted – in particular the praise for staff working within the unit who worked tirelessly to support patients and families throughout this time. The oversight board has also endorsed the steps we have been taking over the past year to improve, and this is also encouraging.
“Nevertheless, there remain lessons for the board to learn and we are committed to implementing the recommendations in this interim report and to continuing to work with the oversight board as they conclude their work, including the ongoing case note review.”
The Scottish Government has also published its response to the independent report published in June.
Freeman said a number of initiatives are already being taken forward, including the establishment of the National Centre for Reducing Risk in the Healthcare Built Environment.
She said: “The interim report from the oversight board includes clear recommendations for how QEUH can strengthen infection prevention and control and it includes important learning that can be applied to the future design and build of healthcare facilities.”
Labour MSP Anas Sarwar said: “It’s clear there were catastrophic failings from the hospital management.
“Families deserve closure, which is why we must ensure they receive all the answers they seek – and there is still a great deal of work to do to deliver justice.”
Scottish Conservatives health spokesman Donald Cameron said: “This report will make grim reading for the parents and loved ones of the children caught up in the infection incidents.
“It is now clear that both leadership and communications were lacking at the health board and this inevitably led to the failures identified in the report.
“Any failures in infection control procedures are unacceptable, the health board must ensure that this is an area which the highest standards are implemented throughout.
“It is without question that the report’s recommendations be implemented with haste and progress monitored closely.”
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