Root cause of harmful bacteria within hospital not found, inquiry told

A hospital was unable to identify the root cause of certain forms of harmful bacteria that infected a number of patients, an inquiry has heard.

Dr Emilia Crighton, director of public health for NHS Greater Glasgow and Clyde, gave evidence on Friday before Lord Philip Brodie at the Scottish Hospitals Inquiry.

The inquiry is examining the design, construction and maintenance of the Queen Elizabeth University Hospital (QUEH) in Glasgow and the Royal Hospital for Children on the same campus, including looking at issues with ventilation and water contamination. It was launched in the wake of deaths linked to infections.

Various forms of bacteria found on the campus were discussed at the hearing on Friday, including mycobacterium chelonae, which can cause skin infections, chronic breathing problems, and can affect multiple organs in people with weakened immune systems.

The inquiry heard the QEUH’s own water supply was infected with a number of bacteria, and a number of barriers were used, including chlorinated filtration measures, to try and curb the spread to patients.

However, with patients still becoming infected, staff began to think there were multiple sources, or “reservoirs” where infections grew.

At the time, Dr Crighton chaired the hospital’s incident management team (IMT) which examined the causes of the bacteria.

Fred Mackintosh KC, senior counsel to the inquiry, asked the witness: “To what extent was your approach as chair of the IMT based on the idea that you were looking for one common reservoir?”

She said: “I was looking for one or a few, or whether there was an intersection in practices.”

He then asked: “I’m just wondering here whether part of the difficulty of the IMT might have been that there were multiple possible sources going on at once?”

Dr Crighton replied: “The IMT and the detailed root cause analysis could not identify a single point of infection, therefore there might have been different sources of infection.”

She went on to explain that reservoirs, or source areas of the bacteria, can range from anything from a sink, an infected person’s gut, the hospital water supply itself, or even from dust on the surface of chilled-beamed pipes with infected water inside.

Mr Mackintosh then cited a report given to the inquiry, which found the hospital failed to identify a common source.

“It would be meaningless if there was more than one reservoir, wouldn’t it?,” he asked.

Dr Crighton said: “It wouldn’t be meaningless. It means that there isn’t a particular source.”

He cited part of her witness statement which was submitted to the inquiry.

He asked: “Would you agree with me that your statement at paragraph 28 seems to suggest the failure to identify a common reservoir was an important and a significant finding?”

Dr Crighton insisted that while it was important, it was not considered a serious defeat for the hospital.

She said: “It was an important and significant finding in a way that there wasn’t a major point of failure.”

The inquiry resumes on Tuesday, and will hear evidence from Dr Teresa Inkster.

The inquiry will examine the extent that non-compliance with relevant regulations and guidance led to ventilation and water contamination issues at the Glasgow hospital.

The hearing will also explore the actions taken to resolve these issues after the handover in 2015 and the extent of their effectiveness.