Significant failings over infection prevention and control, governance and risk management have been found at the Queen Elizabeth University Hospital (QEUH) in Glasgow.
The independent case note review, led by Professor Mike Stevens, investigated 118 episodes of serious bacterial infection in 84 children and young people who received treatment for blood disease, cancer or related conditions at the Royal Hospital for Children.
It found a third of these infections were “most likely” to have been linked to the hospital environment and that two of the 22 deaths were, at least in part, the result of their infection.
Health secretary Jeane Freeman said: “Patients and their families should not feel unsafe in our hospitals, and staff should not be afraid to speak out as whistle-blowers if they have serious concerns.
“These findings, which will inform the ongoing public inquiry, do not fault the quality of care provided by frontline NHS Greater Glasgow and Clyde (NHS GGC) staff, but they do highlight serious failings at the health board level.
“Efforts have been made to improve and adopt the culture of transparency, openness and clinical leadership I expect.
“However, we will continue to work closely with the Board to ensure these are demonstrably embedded – to provide the assurance patients and their families deserve, and also so that these lessons can be considered more widely across NHS Scotland.
“I want to again extend my deepest sympathies to the families of patients who died, and to everyone who has been affected as a result of the issues raised, on top of the significant distress, anxiety and disruption they will already have faced with loved ones in hospital.”
The infection episodes resulted in longer hospital stays for patients and the need for additional treatment, as well as delays in planned treatment in some cases.
A third of infection episodes were rated as having a severe or critical impact on patients.
The expert panel has made 43 recommendations, including improvements in environmental surveillance and how water sampling and testing are used.
Individual reports will be prepared for the families of those patients affected by the infections at the QEUH.
They will also have the opportunity to meet with a member of the expert panel.
Jane Grant, chief executive of NHS GGC, said: “This has been a very challenging time for patients, families and staff and I am truly sorry for this.
“For families, children and young people, undergoing cancer treatment is already an incredibly difficult situation and I very much regret the additional distress caused.
“Whilst we have taken robust and focused action to respond to issues, and at all times have made the best judgements we could, we accept that there are times when we should have done things differently.
“I would like to thank our staff who have worked so hard in difficult circumstances to deliver quality care, putting our young patients and their family at the centre of everything they do.
“With the improvements that have already been made and that continue to be made, infection rates at the hospital remain low.
“Patients and families can have confidence in the care they receive and in the environment within which they receive it.”