Clostridium Difficile-associated Disease
Good morning. The first item of business is a Labour Party debate on motion S3M-2524, in the name of Margaret Curran, on clostridium difficile-associated disease in hospitals.
This debate is vital, given that it focuses on one of the most serious health crises of recent years. I understand that families who lost loved ones will be in the chamber this morning, and I know that Professor Hugh Pennington, a leading and well-respected expert in the field, is with us today, too.
Let us remind ourselves of the truly appalling context of this debate. From December 2007 to June 2008, 55 patients were diagnosed with C difficile at the Vale of Leven hospital, 18 of whom either died as a direct result of C difficile or had C difficile recorded as a contributory factor on their death certificates.
The report of the independent review that was undertaken makes grim reading. It reports a catalogue of failures in infection control and surveillance; consequential failures to control admissions, discharges and patient transfers in infected wards; lack of investment in facilities for infection control and patient isolation; confused, complex and deficient management structures; and deficiencies in clinical leadership and accountability.
Given all that we know and all the resource that we commit, how can it be that Greater Glasgow and Clyde Health Board found out about the deaths only because the press alerted it to them? That is perhaps one of the most striking aspects of the situation. The stark and unpalatable fact is that, apparently, the local newspaper, the Dumbarton and Vale of Leven Reporter, had in place a more effective surveillance system than the national health service did.
Although the report has given us some welcome information—we pay tribute to those who contributed to it and who did their work in a very short time—it is widely acknowledged that many questions remain unanswered. Why was no effective surveillance in place at the Vale of Leven hospital? Who was responsible? Is the situation similar elsewhere? Should we have other worries about hospitals in Greater Glasgow and Clyde or throughout Scotland? How many patients were moved into infected wards after the wards could reasonably have been closed and lives could have been saved? Can we be confident that all hospitals have an effective surveillance system in place? Ultimately—this is a matter for the Parliament—how do we learn the lessons and stop the same situation happening throughout Scotland?
Those are important questions for the relatives and the health service in Scotland, and they require to be answered, which is why there is such a substantial case for a public inquiry. Public inquiries have been commissioned in Scotland before, such as for Stockline and the circumstances of the Shirley McKie case. Many members have argued for public inquiries in different circumstances. Given the circumstances that I have described and the issues that have emerged, surely it is legitimate to put a public inquiry on the agenda.
This is the Parliament's opportunity to tell the minister that, notwithstanding your earlier decisions and your other options, a public inquiry must be on your agenda and you must return to Parliament with your response when you consider all the issues.
As Professor Pennington, an internationally respected biologist, has said, the case for a public inquiry is very strong indeed. Any other way of proceeding would be highly unlikely to address the entirety of the systems failures that were exposed by the events at the Vale of Leven hospital.
I understand that other options are available, but the core of our argument is that, given the severity of the circumstances in this case, the fact that the investigations so far are incomplete, and the wider lessons that public services in Scotland have to learn, a public inquiry should absolutely be on the agenda. We have deliberately asked the minister to come back to Parliament to ensure that she can explain her decision.
I hope that the Parliament will vote to support the motion. Doing so will mean that we recognise the scale and depth of the tragedies that took place at the Vale of Leven hospital and that we understand that we do not as yet have the explanations that we need or the means to learn the full context. That is the core of the argument for a public inquiry. The families must get the facts and explanations that they deserve. More broadly, Scotland must get the opportunity to undertake the required assessment of these appalling circumstances and to learn the wider lessons. In that context, I hope that the Parliament will support the families in their call for a public inquiry.
I hope that in this debate we will move beyond the party-political points that might be required. I will have my opportunities to hold the minister to account and I will do so with my usual energy, but this is a time for the Parliament to move beyond that.
Our commitment is to the families. We must ensure that they get the answers that they deserve and show our support for them and our recognition of what they have experienced. More broadly, this is an opportunity for the Parliament to speak with one voice and to say to the minister that, given the severity of the circumstances and the tragedy involved, we think that a public inquiry is required.
When we consider the debates that we have had over many years and the occasions on which public inquiries have been argued for, we can see that this is perhaps one of the strongest cases for having a public inquiry. We have a duty to be consistent in our arguments. We have argued for public inquiries in the past. It is legitimate to be consistent and to show true faith with the families. We must also respect those who work in the national health service and acknowledge the challenge that we face in Scotland with infections of this order.
We must do our duty. We must ensure that we support the families and that we truly learn the lessons, so that we can say with some degree of confidence and respect that we will never allow the terrible circumstances of the Vale of Leven hospital to happen again. The best way to do that is to support the motion.
I move,
That the Parliament notes with deep concern the outbreak of Clostridium difficile at the Vale of Leven Hospital; considers the report from the independent review team to be a helpful starting point but believes that there are still serious questions to be addressed; notes the referral of the report by the Cabinet Secretary for Health and Wellbeing to the Crown Office and Procurator Fiscal Service to consider what action should be taken; recognises and supports the substantial case made by the families of Clostridium difficile victims for a public inquiry; notes that the Scottish Ministers can instruct such an inquiry under the Inquiries Act 2005 and acknowledges the need for wider lessons to be learned throughout the NHS in Scotland in preventing and tackling Clostridium difficile, and therefore calls on the Cabinet Secretary for Health and Wellbeing to return to the Parliament to make a statement when the views of the Crown Office and Procurator Fiscal are known.
I am pleased to respond to the motion. First, I acknowledge the contribution of the families of those who died as a result of the C diff outbreak at the Vale of Leven hospital. I have already apologised to them directly on behalf of the NHS for the loss that they have suffered and for the failings of NHS Greater Glasgow and Clyde, which Margaret Curran has already narrated. I take this opportunity to reiterate those sentiments.
There is no issue to which I attach greater importance than the battle against infection in our hospitals. I know from personal experience the devastation that it causes for patients and families. I know that fear of infection undermines confidence in our national health service. As both a user of the NHS and Cabinet Secretary for Health and Wellbeing, my commitment to ensuring that everything possible is done to combat infection is absolute.
I do not underestimate for a moment the scale of that challenge. The point prevalence survey that we published last year revealed that one in 10 patients in our acute hospitals had an infection, which is entirely unacceptable. That said, there are, of course, some encouraging signs. Methicillin-resistant staphylococcus aureus rates are at their lowest level in Scotland since surveillance began. Evidence is emerging of the success of new approaches in fighting C difficile. In Lothian, for example, the use of the care bundle approach promoted by the Scottish patient safety programme reduced C diff by 50 per cent in the two hospitals in which the approach was piloted. We need to ensure that that approach quickly becomes the norm in Scotland.
Although there are encouraging signs, I am absolutely clear that there is no room whatever for complacency. As we all know, the scale of the problem is large and the nature of infection is complex—as soon as we get on top of one infection, it is likely that others will emerge. We must continue to up our game, which is why we are investing £54 million over the next three years in measures to help to reduce infection. It is why we have in place a robust hospital-acquired infection action plan and a new policy on antimicrobial prescribing. It is why we will continue to demand high and continuously improving standards of cleanliness and hand hygiene in our hospitals, and it is why tackling infection is a central plank of the new Scottish patient safety programme. It is also why we will consider carefully the form of assessing NHS boards against the new NHS quality improvement standards on HAI now and in the future.
Lastly, the importance of tackling HAI is why we and I personally will never shirk from learning lessons when standards are not as they should be. I had no hesitation in ordering an independent review of the dreadful circumstances that occurred at the Vale of Leven hospital in the first half of this year, and we have acted to ensure that all the recommendations of that report and the accompanying Health Protection Scotland report are taken forward as quickly as possible.
That brings me to the issue of a public inquiry. Let me say first—as I said to the families involved when I met them—that I understand entirely the call for a full public inquiry. The fact that I have powers under the Inquiries Act 2005 to order such an inquiry is not, and never has been, in dispute. I am not just aware of those powers; I have already exercised them in ordering a public inquiry into the hepatitis C situation. I also want to make it clear that such a course of action has never been ruled out, and I do not rule it out today. However, the findings of the independent review team were so serious—Margaret Curran mentioned some of them—that an immediate referral to the Lord Advocate was both necessary and appropriate.
As a result of the referral, the area procurator fiscal for Argyll and Clyde is conducting a full investigation into all the facts and circumstances surrounding the outbreak at the Vale of Leven and will report the findings to Crown counsel. It would be wrong of me to pre-empt what the investigation might find, but members are aware that a range of different actions are open to the Crown Office. For that reason, it is right to allow that investigation to conclude before any further decisions are taken by ministers. If ministers took a decision at this stage—or if I said more than I have already said about what further decisions might be appropriate—we would be in danger of pre-empting and prejudging the outcome of the Lord Advocate's considerations.
It is, of course, my intention to make a further statement to Parliament at the conclusion of those investigations, to comment on them and to announce any decision on further proceedings. I have no difficulty in giving an undertaking to Parliament today that I will make such a statement at the earliest opportunity. In the meantime, the Government and I will continue to take all possible action to prevent and control the scourge of infection in our hospitals. In doing so, I hope that we will have the support of all members.
I move amendment S3M-2524.1, to leave out from "and supports" to end and insert:
"the case made by the families of Clostridium difficile victims for a public inquiry; acknowledges the need for wider lessons to be learned throughout the NHS in Scotland in preventing and tackling Clostridium difficile; notes that Scottish Ministers can instruct a public inquiry under the Inquiries Act 2005, and therefore calls on the Cabinet Secretary for Health and Wellbeing to return to the Parliament to make a ministerial statement when the views of the Crown Office and Procurator Fiscal are known."
I congratulate the Labour Party on according the important subject of the deaths of 18 people and the contraction of C difficile by 39 others at the Vale of Leven hospital a debate in the chamber.
As a West of Scotland regional member, I shared the general anger and dismay as events unfolded earlier this year. I pay tribute to the local member Jackie Baillie, and once again on behalf of the Scottish Conservative party I express our sympathies to all the relatives concerned for their loss and the circumstances that brought about the loss—which, in most cases, will have been entirely unexpected. I join Margaret Curran in welcoming their presence in the gallery today and I welcome the moving of her motion. Let me also say that not only were the deaths unexpected, they were inexcusable, and they may well have been avoidable.
Relatives have faced something of a dilemma. There was clearly a colossal failure at the Vale of Leven, but my impression is that local people are understandably but needlessly nervous that by pursuing the investigation of the tragedy they may in some way contribute to a further general undermining of the hospital.
Let us be clear, as the independent review was: the threat of closure under which the Vale of Leven hospital laboured for more than a decade led to a significant lack of investment and, one has to suppose, a general lack of interest from the management of NHS Greater Glasgow and Clyde. However, we should not confuse a desire to investigate the deaths properly with any lack of support for the future of the Vale of Leven, a hospital for which tens of thousands have demonstrated their sustained support.
The independent review is excoriating: there was a failure of leadership and supervision and inconsistent infection control and isolation practice. The hand-washing facilities were inadequate, there were insufficient toilets and there was a lack of space between beds. Since the outbreak and the independent review, NHS Greater Glasgow and Clyde has announced urgent investment to remedy those basic failings, and to a significant extent other recent announcements have made clear that there is a permanent future for the Vale of Leven hospital.
The independent review also uncovered the frankly astonishing lack of clarity among staff or supervision of staff when it came to basic hygiene. There was a lack of understanding about the role of soap and water in the control of C difficile, despite health board assurances of adherence to all manner of action plans. That apparent paying of lip service to fundamental standards should concern us in our examination of the broader lessons that should be learned throughout the NHS.
Scotland does not have a proud record on hospital-acquired infection. Our incidence rates are higher than those of our United Kingdom neighbours, and the costs of £183 million are substantial and were unheard of even a decade ago. In 2006, 164 lives were lost to C difficile—the chilling reality that underpins any financial cost.
I have detailed the foregoing without any political spin or attribution of political blame. Like Margaret Curran, the Scottish Conservatives are not interested in rooting today's debate in the customary partisan political exchanges. We will not indulge in denunciations of political masters past or present. We want the lessons learned to have an impact on the NHS battle against health care-acquired infections throughout Scotland.
We believe in a named individual with executive authority being in charge of our hospital wards, and we appreciate that the Government's senior charge nurse review may move matters further in our direction. We mean executive control: the power to direct staff, visitors, patients, volunteers and even the hospital royalty—consultants. They should have the power not just to direct but to instruct—to be able to have facility deficiencies rectified expeditiously and without reference to an anonymous bureaucratic approval process.
In one important respect, however, we agree with the cabinet secretary: the independent review is now with the Crown Office and procurator fiscal, and until we know their determination it is premature to call for a public inquiry. Admittedly, that is at one level a judgment about the nuances in the Labour motion, but we do not feel that the relatives' real concerns are best aided by adopting a resolution that is underpinned by premature calls for a public inquiry.
The courses of action that are open to the Crown Office and procurator fiscal are significant in law and are of the utmost seriousness for the individuals and organisations concerned. We acknowledge the powerful representations of the grieving relatives and that calls for a public inquiry may have their moment—sooner rather than later. A public inquiry is, to use Margaret Curran's phrase, "on the agenda". However, for today, we believe that due process must be allowed to complete, and we look to the cabinet secretary to make the Government's position clear with a further statement to Parliament when the views of the Crown Office and procurator fiscal are known.
Liberal Democrats also acknowledge the real grief experienced by the families and their tremendous efforts in trying to get to the bottom of why their relatives suffered such an untimely death.
Liberal Democrats support the call for a public inquiry simply because the two reports into C difficile—one specifically into the Vale of Leven hospital and the other into all acute hospitals in Scotland—provided prima facie evidence of endemic management failures in the control of health care-acquired infection.
As has been stated, the Vale of Leven report pointed out that the health board's persistent attempts to close the hospital in the past 10 years had resulted in a critical reduction in disease control facilities. In addition, the hospital site appeared to be given a lower priority than other sites in the implementation of disease control policies, systems and staff development. Sadly, the Vale of Leven hospital is not the only hospital that Greater Glasgow and Clyde NHS Board has been attempting to close for the past 10 years.
The report into the acute hospitals in Scotland pointed to the limitations of its own review. It concentrated, understandably, on the surveillance systems for health care-acquired infection, but it made little comment on the adequacy or otherwise of the management systems that are in place across Scotland to combat health care-acquired infection. I stress management failures, which Jackson Carlaw also mentioned, because we have to be clear that there is no evidence that ordinary staff in our hospitals are in any way responsible for the increased incidence of health care-acquired infection. Indeed, the Royal College of Nursing has pointed out that nurses in Scotland are consistently found to be the staff group that complies most with hand hygiene measures. The RCN also points out that the new senior charge nurse role, which is to be established by health boards, will be important in tackling health care-acquired infections. No doubt the establishment of that role and the measures to which the cabinet secretary referred in her speech will assist, but they will not address the question whether the management systems are adequate and robust.
The cabinet secretary has acknowledged that the Scottish ministers have powers to establish an inquiry and that she has done so in the past. However, she also stated that because the Lord Advocate has asked the area procurator fiscal to inquire into the circumstances surrounding the deaths, it would be premature to call for a public inquiry. Liberal Democrats accept that position, but only up to a point. We draw a distinction between an inquiry by the Crown Office into matters of criminality and a public inquiry to establish the facts. Patients and their families have legitimate concerns. They seek not only to ensure that justice is done and is seen to be done but the satisfaction of knowing what happened and understanding what gave rise to the events, even if no criminality was attached to the circumstances. No matter whether Crown counsel decides to pursue a prosecution in relation to Vale of Leven hospital, there remains a compelling case for a public inquiry to establish the facts that were not established by the earlier enquiry and to restore public confidence in the systems that are in place.
The decision as to whether there is sufficient evidence to mount criminal proceedings is properly a matter for the Crown Office. Liberal Democrats do not accept, as the Government amendment clearly implies, that calling for a public inquiry implies criminal culpability. I accept that if criminal proceedings proceed, the timing of an inquiry would have to be fixed to ensure that evidence that was material to those proceedings was not compromised in any way. Because of that, I am happy to accept the last line of the motion, which indicates clearly that the timing would be in the hands of the cabinet secretary, irrespective of whether criminal proceedings are instructed.
Fifty five people were affected and 18 people are dead. Those are the official figures that indicate when Clostridium difficile was recorded on death certificates. It is becoming clear that more deaths went unrecorded. Whether recorded or not, the scale is unprecedented. This is Scotland's, if not the United Kingdom's, worst mortality from C diff. The problem is not unique to the Vale of Leven hospital, nor to the hardworking staff there. The incidence of C diff is rising—there have been outbreaks in Stobhill, the Victoria infirmary, Wishaw, Aberdeen, Fife and now the Royal Alexandra hospital in Paisley—but what has been different is the response.
People have claimed that the problem is caused by underfunding or neglect, yet the cabinet secretary herself has said that the prevalence rates at the Vale of Leven are the same as in hospitals in the rest of Scotland. She has also said that what happened at the Vale of Leven was a failure in surveillance. Going by her own words, the issue is much more complex than such claims suggest. If anyone remains in doubt, contrast the Vale of Level hospital and the Victoria infirmary, which are similar in age and condition. At the Victoria, C diff was discovered one day, the ward was closed the next day and the emergency outbreak control team met within 48 hours. At the Vale of Leven, people were dying and we waited six months before the emergency outbreak team met. That is about monitoring and surveillance.
As the constituency MSP for Dumbarton, I have been privileged to work with some of the bereaved families, and I join others in welcoming them to the chamber. I pay tribute to their courage and their determination to find answers to what happened to their relatives. Make no mistake, they do not seek to apportion blame; rather, the aim is to ensure that we will never again see a repeat of the scale of death that occurred at the Vale of Leven hospital at that or any other hospital.
We now have the report from the independent review team. That is a welcome first step but, as others have said, questions remain unanswered. From the families' perspective, it is insufficient: they do not know what questions were asked, what documents were considered or even what people said. The report does not deal substantially with the wider relationships with Health Protection Scotland and NHS Scotland.
The families have been clear and consistent: they want a public inquiry. I welcome the fact that the cabinet secretary has referred the matter to the Crown Office. It is considering whether there should be a fatal accident inquiry, a public inquiry or any criminal prosecution. Having said that, I know that the cabinet secretary has the power to initiate a public inquiry under the Inquiries Act 2005, to which she referred. It states that a minister can call a public inquiry if
"it appears … that—
(a) particular events have caused, or are capable of causing, public concern, or
(b) there is public concern that particular events may have occurred."
Of course, the matter is not reserved within the meaning of the Scotland Act 1998. There is clear public concern. There have been 18 deaths at the Vale of Leven and many more throughout Scotland. Lessons need to be learned fast.
Why should there be a public inquiry rather than a fatal accident inquiry? A fatal accident inquiry would take place before a sheriff, the focus would be too narrow and it could consider only what happened at a given hospital over a given period. The recommendations would not be binding, the inquiry would be adversarial rather than inquisitorial and, perhaps most significant, a fatal accident inquiry would exclude and disenfranchise the victims who survived. In contrast, a public inquiry would be wider in scope, the recommendations would go straight to ministers and the inquiry could propose legislation. A public inquiry could deal with all who were affected, and the fact that such inquiries are chaired by a judge would send a strong signal of the seriousness of the matter.
In a former existence, the cabinet secretary called for many public inquiries—I have not always agreed with her—and in government she and her colleagues have initiated a number of them. I hope that she will agree that it is right that the victims of C difficile should benefit from a public inquiry, too. However, this is not only about the victims; it is about ensuring confidence in the national health service. The problem of C diff requires to be investigated as widely as possible. We need to put in place the right system, the right guidance and the right resources to ensure that we minimise the possibility of such events ever happening again. That objective surely is shared by the whole Parliament.
We need an independent inspection and monitoring regime for HAIs in Scotland. If I went on the internet, I could run off an environmental health inspection report about my local restaurant and takeaway, a report about the performance of my local school and a report about my local care home. I could even run off a report about the Vale of Leven hospital tea bar, but I could not do so for a report about the hospital itself.
Issues such as whether there is a need for an independent inspection regime are too wide for a fatal accident inquiry—that is the terrain of a public inquiry.
This debate is about Parliament's view, not about the minister taking a view. It is about how we move forward to provide answers for the bereaved families, how we support NHS staff and how we provide confidence in our NHS. A public inquiry gives us the basis for doing that.
I acknowledge, as other members have done, the distressing circumstances that have brought us to this debate, which will never be a party-political one.
I thank Jackie Baillie for her speech and acknowledge her powerful representation of her constituents in this tragic matter. The statistics are damning in themselves, but we all acknowledge that each of those statistics represents an individual person and leaves an enduring trail of tragedy for family members and friends.
This must also be a difficult period for staff at the hospital. There will be very good staff in the Vale of Leven hospital—some of them will be very good indeed—and they must feel stigmatised by the cloud that has hung over the hospital.
I will not go back over the review report, to which other members have referred. I will move on from the specific tragedy at the Vale of Leven hospital to consider the general issue of hygiene and cleanliness, with which, as many of us knew anecdotally, there are serious problems in hospitals throughout Scotland. Hygiene and cleanliness used to be taken for granted in my younger days, never mind my mother's day. The present problems can be attributed partially to the break-up of the esprit de corps that used to exist in our hospitals, whereby the cleaner and the janitor were part of the same team as the much-lauded consultant. Quite often, it was the cleaner or the janitor who had the time to speak to patients and to ensure that they were comfortable. Now we use agency nurses. I am not blaming them, but their connection to hospitals is transitory. They are rewarded through their salaries, but they do not feel part of the hospital family. That feeling, which money cannot buy, has been lost.
We should also consider the more relaxed approach to visiting hospitals that has been adopted, and which I have been guilty of. Sometimes six or seven people surround a bed that is close to another bed, and visiting hours in many hospitals are no longer restricted. It goes without saying that that must cause simple hygiene problems. The issue is largely practical. As someone important once said, there is nothing to beat soap and water for your hands. Simple measures must be taken, such as cleaning the walls and floors of hospitals and ensuring that the bed linen is clean and that wards are not crowded.
I want to challenge what Jackie Baillie said about the holding of a fatal accident inquiry. She said that such inquiries are adversarial, but they are not—they are inquiries. I have called for two fatal accident inquiries in my part of the country—one on the death of Pascal Norris from anthrax and the other on the death of Irene Hogg following an inspection by Her Majesty's Inspectorate of Education. It was not mandatory to hold a fatal accident inquiry in those cases, in which due process was followed. Both cases went first to the procurator fiscal to consider whether there should be criminal proceedings, because such proceedings, in which the standard of proof is "beyond reasonable doubt", take precedence. The process then moved on to consider the question whether it was appropriate to hold an FAI.
What is important about FAIs is that they are extremely flexible. At any point in an FAI—which is an inquiry—the sheriff or the senator in charge can decide that criminal proceedings are appropriate and that the inquiry must be stopped. It might even be decided that a public inquiry should be held. Rather than a decision, an FAI produces recommendations and determinations. That is why the standard of proof is different.
I accept what the member says about fatal accident inquiries, but the broader issues are the problem. Clostridium difficile-associated disease is an issue not just for the Vale of Leven but for the whole of Scotland and the whole of the NHS.
With respect, I think that I mentioned that when I discussed the general problem of hygiene in our hospitals. The broader issues might emerge in a fatal accident inquiry. Such an inquiry might not even be held, if the procurator fiscal decides that there is sufficient evidence to pursue a criminal prosecution.
I understand the call for a public inquiry—that would be the first thing that I would call for, were I a member of an affected family. However, we must keep a cool head and think about how to get to the root of the problem. The best way of examining forensically what took place would be to find out first what the procurator fiscal has to say about criminal culpability. If there is no criminal culpability, the holding of a fatal accident inquiry will allow the sheriff or judge in charge to make determinations about the way forward. An FAI will not prevent us from considering all the issues; it will give us an opportunity to examine all the evidence coolly and to take a range of views on how to deal with the problem. It is in the interests of all patients in Scotland, especially our older patients, that we get to the bottom of what has been happening for a long time in Scotland's hospitals.
Other speakers have made it clear that Clostridium difficile-associated disease is not just a problem in one hospital. On 5 September, the Paisley Daily Express reported that the fact that there had
"been eight cases of the deadly Clostridium Difficile infection in one ward at the Paisley hospital over a four-week period … was a contributory factor in the death of one patient",
so it is clear that people in my constituency are worried about what is happening in our hospitals.
I welcome the content and tone of the cabinet secretary's speech. I thought that she made some helpful comments and recognised the scale of the problem. This is a debate on which we should try to reach some common ground on behalf of the wider public. People will not forgive us if we are seen to squabble for party-political reasons over an issue on which there is general agreement. I worry that the cabinet secretary might inadvertently—I am not suggesting that she is doing so deliberately—be teasing people with the possibility of a public inquiry. She said that she did not rule out such an inquiry, but that issue is separated out in the amendment, which is otherwise similar to Labour's motion.
I hope that during the day, the cabinet secretary might reflect on where we are. We do not want to give out a signal to the general public that politicians are squabbling and cannot agree on taking serious action on a significant issue. I hope that we will send out a clear message that we are intent on improving the situation in our hospitals. Several speakers have highlighted the problem. Christine Grahame was right to mention some of the cultural and practical issues in our hospitals. Staff are not deliberately casual, but the fact that they can move from one institution to another and not have any long-term commitment to a hospital can cause problems.
Like the cabinet secretary, I have experience of elderly relatives suffering hospital-acquired infections. The state of cleanliness of some wards leaves a lot to be desired. There seems to be some confusion about who is responsible for cleaning certain things at certain times. Sometimes unclean and unsafe conditions are left for far too long.
Jackie Baillie made a good point about inspection. Why is it that we can find out about the tea bar at the Vale of Leven hospital, but we cannot find out before we go into a hospital whether it has a bad record, relative to other hospitals, on cleanliness and hospital-acquired infection? We should put such information into the public domain.
Like the member, I have many constituents who use the RAH. They would like Government front benchers to tell them why the Government is suggesting that we proceed with a health board by health board web reporting system rather than a hospital by hospital reporting system. After all, it is in hospitals, not health board headquarters, that people acquire infections. The prerequisite for an inspection regime is the ability to obtain data hospital by hospital. The decision to move to a web-based reporting system was made during the recess—
Interventions should be brief.
It would be helpful to be given a justification for the decision that information is to be provided health board by health board, rather than hospital by hospital.
The member must begin to sum up, I am afraid.
I do not disagree with Wendy Alexander. Before they go into a particular hospital, patients should have the right to access the data for that hospital. I see no reason why we cannot have unannounced inspections of the cleaning and safety standards in hospitals. It is a concern that more progress seems to be being made on the issue in England than is being made here. We should be big enough to learn from what is happening elsewhere.
I acknowledge that time is short and that other members want to speak. Suffice it to say that we must find a way of coming together to take action on what is a significant issue for the public. There is an opportunity for us to have further debate on inspection regimes and other specific issues on which practical suggestions have been made. The last thing that we should do on such a major issue that has had tragic consequences is divide along party-political lines over of what will be seen as splitting hairs and playing with words.
We meet in the light of the personal tragedies at the Vale of Leven, but many of us have our own experience of the problem and its environment. I spend a lot of time as carer to two 90-year-olds. My father has prostate problems, which mean regular hospital visits. Forty years ago, as a postgraduate student, I was the first archivist of Edinburgh royal infirmary, and found out that before the age of Lord Lister and antisepsis, patients often did not expect to leave hospital. Hospital-acquired infections are nothing new.
Are we reverting to the pre-Listerian time? Comparisons with Germany suggest that we have 10 times the occurrence of hospital-acquired infections, but why? Besides resistance to antibiotics, we have perhaps greater environmental problems, such as old buildings. We use inappropriate floor coverings, for example carpets instead of tiles or linoleum—I declare an interest as an MSP for the Kirkcaldy area—which is seen to have an antibiotic effect. I have never seen a carpet in a German hospital. Hospital notes, making their progress round the wards, can appear rather toxic, since they are grubby and, in the case of elderly patients, often date from a long time back.
There are social factors. Besides our alcohol problem, we have three times the German rate of drug addiction. Accident and emergency at Borders general hospital can be a scary place for the staff, let alone the patients. Can people from a chaotic background be expected to observe clinical rules? Inevitably, the problems will increase in areas that have profound social difficulties. There has been a lack of investment in the Vale of Leven, but even favourable developments, such as the replacement of a hospital or of facilities in a hospital, can have unfavourable effects. How many of us have been in a hospital that seems like a building site, where everything is in a temporary state, making one wonder whether everything is being kept up to the necessary standard?
Three and a half years ago, I was constantly in the Middlesex hospital in London. The condition of the hospital was poor because a new building—the new University College London hospital—was only weeks from opening. However, the new building could not affect the patient at whose bedside I waited, as she was in the last stages of cancer. She was tended by the Middlesex staff clinically—in the true Latin sense of the word—and with love. However, it was a hospital in its last weeks, and the sources of possible infection—ill-cleaned corridors and public toilets, and the absence of hand wipes and of facilities for adequate hand washing—were all too obvious. Hospital improvement is good, but it always leaves a vulnerable interval.
It is important that we establish the primacy of hygiene. That means keeping all infrastructural support in-house. In NHS Wales, which has a good record in combating HAI, all cleaning is done in-house, and the guiding principle is hygiene. Before that, many contractors had left it to cleaners to wash their uniforms at home and wear them when travelling to work, increasing the risk of infection transmission. How much of that still goes on?
The issue also involves the wider public. Earlier this year, I got stick from the Daily Record and The Sun for objecting to teenagers planting their shoes on bus seats. All the buses on which I travel pass the Borders general hospital, and medical staff use those seats. There is a major contamination possibility there—just consider where those shoes have been. That represents the sort of casually indifferent behaviour I have almost never seen among young people in Tübingen, which is a major hospital centre in Germany. I think that there is a reason for that, which might also be a way forward. Most German teenagers spend a year doing social service, often as a hospital orderly, a worker with the elderly or a paramedic. Such social service is far more demanding than any form of military service and, as anyone who has worked with youngsters here who have done first-aid training will know, that experience, particularly over a year, does not just change lives, but saves them.
I support the motion in the name of Margaret Curran and pay tribute to my colleague and friend Jackie Baillie for her usual tenacity in pursuing an issue with diligence and fortitude. I extend my sympathy and condolences to the relatives who have come here from the Vale of Leven to listen to the debate.
No matter what any member says today, I imagine that those relatives will be inconsolable in their grief over the loss—which may have been avoidable—of their loved ones. I do not blame the Government for the existence of such infections—no one would dream of doing so. However, what is important is how we as politicians react to the situation. Lives have been lost, and the question is how avoidable each death from the dreadful infection C difficile was. A public inquiry can tell us, and holding one would send out a political message. The kind of inquiry that you are talking about, cabinet secretary, does not give the issue the gravity and urgency that it requires, nor does it address the crisis of public confidence that exists throughout Scotland. How avoidable were those deaths?
On Sunday, at a constituency engagement in Cardenden, I was told of a patient whose death in the Queen Margaret hospital in Dunfermline may well be another that was caused by contracting C difficile in the hospital. My constituent's mother was admitted to the Queen Margaret in January, and was moved to bay 7B, in ward 7, which had been closed for a week due to a bug. The patients in the bay provided my constituent with all the information; the medical team said nothing. A few weeks later, the family arrived to visit and found their mum in a side ward on her own. No one in the hospital provided the family with any information. At their next visit, the family were greeted by a nurse refusing them entry. An apron and gloves were presented, and family members were advised that C difficile was suspected and that a test had been arranged.
My constituent's mother had visitors non-stop that day—the whole family had unrestricted access. Despite what other members have said, there were no restrictions on being close to the patient or sitting on the bed. My constituent said that the ward was never closed during that period, and that the level of cleanliness left much to be desired. My constituent's mum was then moved to ward 1 in Lynebank hospital.
What I find most shocking in that case is the absence of information for or instruction to visitors. Why was the family not given clear direction and instruction about hand washing, contact with the patient and so on?
The cabinet secretary will be aware that ward 6—a general medical ward—at the Queen Margaret hospital in Dunfermline was closed to new admissions just three weeks ago, after seven patients developed diarrhoea and later tested positive for C diff. Samples were taken to discover whether the patients were infected with the virulent 027 strain of C diff. The results will be known this week.
I reiterate my call for a full public inquiry into the matter. Such an inquiry is important for every patient in Scotland. There is a crisis of public confidence around infection control and, for the reasons so eloquently put by Ross Finnie, there is a compelling case for a public inquiry. What is happening in the Queen Margaret hospital in Dunfermline underlines the need for a full public inquiry into C difficile, so that lessons can be learned from the recent tragedy at the Vale of Leven, where 18 people died. Families have an absolute right to know that when their loved ones go into hospital they will be cared for in clean and safe conditions. Sadly, cabinet secretary, you are not taking on board the message about the difference between a public inquiry and a fatal accident inquiry. The latter is not the way forward.
In February, and again last month, the Dunfermline Press highlighted the issue on its front page. It reported that the number of deaths in Fife hospitals where C diff was mentioned on the death certificate had rocketed from 23 up to 41. A national survey carried out by Health Protection Scotland said that just under 10 per cent of patients at the Queen Margaret hospital had a hospital-acquired infection such as C diff or MRSA.
Cabinet secretary, can you put your hand on your heart and state that you have kept faith with your promise
"to raise the issue with every Board during this summer's Annual Reviews"?
Did you do that with every health board at its annual review this summer?
The member should be winding up.
Finally, cabinet secretary, the constituents whom I represent in Cardenden form part of the Glenrothes constituency. Unless you give us an absolute and categorical assurance that you will go ahead with a public inquiry, I will print every word that you have said on the leaflets that I will put out in the Cardenden and Kinglassie part of my constituency, to say—[Interruption.]
Order.
—to say that you are not taking the case—
The member should wind up.
—for a public inquiry seriously.
Order. I remind members that all their remarks should be made through the chair. If the word "you" is used, it refers to me. Several members have been ignoring that stricture during the debate.
I am fortunate in my constituency in that Caithness general hospital in Wick enjoys an enviable reputation for cleanliness. I have done a short course on hand cleaning, and it is a much more scientific and thorough process than I had realised.
I know something about hospital-acquired infections. Following neurosurgery, my wife went down with MRSA. She survived—we are the lucky ones. We were incredibly lucky. However, I can remember the sickening feeling when someone—after going through major and traumatic treatment in hospital—then goes down with a hospital-acquired infection. I have been there; I have got the T-shirt, and my family has got the T-shirt. I remember the visits and having to wear the gloves, the masks and the whole paraphernalia—just to see my own loved one in hospital. For that reason, I have a real understanding—as do all of us in the chamber—of what the relatives of the 18 people who died so tragically have gone through. I understand exactly where they are coming from.
Jackson Carlaw said that such things are inexcusable and avoidable. It is the avoidable aspect that so sickens us all. He gave the best description of the independent review when he said that it was "excoriating". Indeed it was.
I applaud Jackie Baillie's speech in every way. The point that she made about such a situation never happening again is the real issue. As she said, we are not dishing out blame—this is not a culture of blame—but we have to ensure that safeguards are put in place so that such events are never repeated. We must do that as far as humanly possible, given human intelligence.
Some of Christine Grahame's points were very fair. We must not forget the staff at the Vale of Leven hospital, who will be feeling very down. I would hate to be in their position; they have worked extremely hard and yet their reputation has been damaged. Christine Grahame's point about hospital visitors was absolutely correct—we have all seen examples of such behaviour. Until recently, it was possible to have six people round a bed in a ward and there would be no washing of hands.
Hugh Henry's contribution—complete with Wendy Alexander's intervention, long though it was—was right. We are not interested in health board data; we are much more interested in knowing specific hospital data. As Jackie Baillie said, at the moment we can get information about the tea in the canteen but not about the rates of HAIs in the hospital.
In closing for the Liberal Democrats, I echo what my colleague Ross Finnie said: there is a clear distinction between the work that the Lord Advocate and the Crown Office are undertaking and a public inquiry. The Lord Advocate and the Crown Office are looking into aspects of criminality in what has happened. They may rule one way or they may rule the other way—we know not. However, the issue goes way beyond the Vale of Leven hospital and the Greater Glasgow and Clyde NHS Board. The whole of Scotland and the United Kingdom sat up when people heard of those 18 deaths. The issue is at the back of everyone's mind when they go anywhere near a hospital. Public fear is real. Constituents of mine have died of MRSA, and every death is one too many.
My party believes that a public inquiry is very much in the public interest. As others have said, a public inquiry could do more than the Lord Advocate or any other person could do, and more than a fatal accident inquiry could do. A public inquiry would be wide and—crucially—it would restore public confidence among ordinary people who might be facing hospital treatment.
Of course we will respect the cabinet secretary's views on timing, but Ross Finnie made a point that I hope will be acceptable to the cabinet secretary. He said that one evidence-taking session must not compromise another; they can be dovetailed in order to achieve the best possible outcome for the concerned people whom we represent.
We join others in sending our condolences to all the families who were affected by the outbreak of C difficile and the 18 deaths at the Vale of Leven hospital. The Scottish Conservatives agree with much of Margaret Curran's motion, and we confirm that a public inquiry is not off our agenda.
Undoubtedly, serious questions remain to be addressed. However, where we differ from the Labour Party and its motion is that we support and respect due process, allowing the procurator fiscal fully to investigate the C difficile outbreak and consider what action should be taken. However, we do not rule out supporting a public inquiry at the appropriate time, following the investigations and conclusions. It may be that a fatal accident inquiry will be recommended by the procurator fiscal; it may be that civil proceedings will be taken against Greater Glasgow and Clyde NHS Board; it may be that actions will be pursued against individuals as they are held accountable for the outbreak; and it may be that persistent failures and negligence will be identified. However, we do not wish to pre-empt the findings of the procurator fiscal, and we respect the due process of the investigation.
I also hope that the findings will consider the lives that could have been saved had action been taken at the Vale of Leven hospital at the appropriate time. Given the high level of expenditure on the NHS in Scotland, it is shocking to read the litany of failures at the Vale of Leven hospital, which many members have highlighted. The failures include: underinvestment; ineffective isolation and infection control; lack of leadership; poor facilities; poor information on hand washing and laundry; and failure to monitor antibiotic levels. It is hardly surprising that staff morale was low. All of that should be placed against the statement from Health Protection Scotland that evidence from several countries concludes that hospital-acquired infections are avoidable. Jackson Carlaw and others have made that point.
I will make a couple of points that have not yet been made today. I hope that the cabinet secretary will take up the issue of an inquiry and will consider the problem in a wider context, because it exists not only in hospitals. Infections also exist in nursing homes and care homes for the elderly, and many of those patients are then transferred to hospital. I am not saying that that happened at the Vale of Leven hospital, because I am not familiar with where the patients came from, but when people are transferred they can bring infections with them. We cannot simply concentrate on infection control in hospitals; we have to be just as rigorous in nursing and care homes.
I hope that, when she responds to the debate, the cabinet secretary will advise us what the Scottish Commission for the Regulation of Care is doing in terms of inspections and infection control. What is its role? Is it as rigorous as we hope to be in the NHS? There is no point in considering hospitals unless we consider the whole sector. Neither is the prescribing of antibiotics wholly in the domain of the hospitals. We cannot blame just the hospitals for prescribing antibiotics. Before patients go into hospital, much more needs to be done to reduce the prescribing of antibiotics. That is true for all patients, but especially the elderly.
I welcome the increased use of day surgery, and I also welcome last week's report from Audit Scotland report, which concluded that more procedures could be done by day surgery. Not only would that save money and provide a less disruptive experience for the patient, but it would cut down on hospital-acquired infections, because the stay in hospital would be shorter. We are pleased that the report recommends the empowering role of the charge nurse—something that Conservatives have long called for.
We support the Government's amendment today, and we may well support Labour's call for a public inquiry at an appropriate point in the future, following the current investigations.
In the time that I have available, I will try to respond to some points that were made in the debate. I thank all members who contributed; on almost every occasion, their contribution was considered and helpful.
I thank Margaret Curran for initiating the debate. She narrated some of the report's key findings. As I said on the day of its publication, the report painted a picture of conditions at the Vale of Leven that were entirely unacceptable. That view is echoed by absolutely every member in the chamber.
Jackson Carlaw made a considered speech, in which he raised the important—probably the central—issue of the downgrading of the Vale of Leven over a period of 10 years with the resulting lack of morale among staff and all those who were associated with the hospital. He rightly stated the importance of ensuring the future of the hospital and of ensuring that it gets the investment that it needs. I am pleased that NHS Greater Glasgow and Clyde has given a commitment to the sustainable future of the hospital. I am sure that that is a commitment on which we all will want to hold the NHS board to deliver.
Ross Finnie and I may not be on the same side when it comes to the vote at decision time, but his speech was very good. He drew a distinction between criminal liability and the wider circumstances of a case. I say to him in response that the purpose of the Lord Advocate's investigations is not only to establish criminal liability; criminal prosecution is one possible outcome of her investigations, but not the only one. As other members have said, in theory it is open to the Lord Advocate to order a criminal prosecution, a fatal accident inquiry, or a public inquiry. That range of options is open to her.
I acknowledge Jackie Baillie's role as the local member. As she rightly said, although we are focusing today on the Vale of Leven, the issue is not only for that hospital—infection is a challenge in all our hospitals. The issue is also not new; infection has been a challenge for all our hospitals for many years. Indeed, the challenge is not unique to Scotland; every country is battling it.
I agree with Hugh Henry that the issue should not be made party political. I assure him that he will hear no party-political squabbling from me on the issue—it is far too important for that. Hugh Henry made legitimate points on the nature of assessment and inspection in our hospitals, as did Wendy Alexander when she intervened on him. As I said in my opening remarks, the issue is under my active consideration.
What I am about to say, therefore, is not intended to be party political; it is intended as a statement of fact. The present system of assessment for our hospitals and health boards was put in place by the previous Government, and inherited by this Government. If we are to change the system, instead of making the issue one of politics, I hope that we can come together and agree on changes, based on experience.
I agree with what both Christine Grahame and Christopher Harvie said on cleanliness and hygiene standards. Christopher Harvie made an excellent point on the outsourcing of cleaning contracts. My views on the subject are well known.
Mary Scanlon's point—that the issue applies not only to hospitals—is central to the debate. If one looks carefully at the latest statistics on C difficile, for example, one finds that a quarter of all cases are contracted not in hospital but in the community. The issue must be viewed more widely, as Mary Scanlon said. It is essential that we widen our focus to include homes that the care commission inspects, including nursing homes.
Three questions are at the heart of today's debate. First, should further action be taken? As I said in my opening speech, I understand the calls for further action. If I was convinced that there was no case for further action, I would not have referred the report to the Lord Advocate. I repeat what I said earlier: I have not ruled out anything, including a public inquiry.
The second question is: what process do we pursue in coming to a decision? Having referred the report to the Lord Advocate, it is right that we allow her to consider the various possible courses of action. If a further inquiry were to be made in the future, her investigations would be invaluable in helping us to divine its scope and shape.
The third and final question is: what do we do in the meantime? Notwithstanding action that may or may not be taken, it is essential that none of us gives the impression that we should sit back and await the outcome of some future inquiry before making the improvements that we need to make to ensure that we are constantly upping our game in the battle against infection.
I know that we will return to the issue. I have given an undertaking to return to Parliament at a later stage. In the meantime, I will continue to do everything possible to ensure that we fight infection as effectively as possible. I will do that because, whatever else members think we owe to the families of those who are affected at the Vale of Leven, I am in absolutely no doubt that we owe them that.
C difficile is somewhat different from MRSA. That recognition should be the starting point for the debate. The prevalence of C difficile in the population at large means that, when someone goes into hospital, it is important that every measure is taken to ensure that the infection is not spread or does not become more serious.
Given that we know many of the factors, I will mention just three: overcrowding, poor hand hygiene, and failures in antibiotic policy. Under the previous Administration and continued under this Administration, attempts have been made to tackle some of those issues. For example, overcrowding was exacerbated by delayed discharge, an issue that has been largely eliminated. The Government achieved that in March 2008. I accept that the antibiotic policy that was put in place in 2002 has been updated, but its implementation still needs to be questioned. For example, NHS Lothian has implemented it much more strictly, with good results. That has also been done at the Maidstone hospital in Kent following the outbreak there, and the results have been demonstrated to be effective. The matter has to be taken seriously.
Hand washing is a matter of considerable concern. The cabinet secretary has indicated a target of 90 per cent, which sounds good—indeed, it sounds excellent to have such a target. As Ross Finnie said, we know that nurses are better at hand washing than doctors are. Other measures can also be put in place. One of the problems is that the alcohol gels that are widely used in the system are not the answer, because they do not deal with C difficile. Also, the current inspection regime does not distinguish between hand washing and hand hygiene. There are therefore two flaws in setting the target, which is intended to help to restore public confidence. In the self-reporting that occurs under the inspection regime, staff are not required to wash their hands at all times. The reporting is therefore meaningless, which is regrettable. The issue could be addressed in a public inquiry—
I will finish the point, cabinet secretary, and then let you in.
If one looks at the latest figures under the hand hygiene inspection regime, the denominator—the number of observations—reported by NHS Greater Glasgow and Clyde was 300. However, the number reported by NHS Forth Valley, which is a much smaller board with only two hospitals, was 480. Those figures show that no pattern is emerging from the inspection regime. There is an absolute need for an independent inspection regime. That issue should be looked at.
I wanted to agree with the point that Richard Simpson was making when I rose to intervene. Notwithstanding my previous comments on a public inquiry, I assure him and the chamber that I do not want to wait to be told in a public inquiry report that I must ensure that any flaws or failings in the current system of hand hygiene are rectified. We should be getting on and doing that now.
I absolutely accept that. The problem is how we can see the whole picture.
Many things cannot be understood by reading the report conclusions. For example, why did 55 cases produce 18 deaths at Vale of Leven? The expected mortality level for C difficile—and there is such a level—is around 2 to 3 per cent, although in associated cases it may go up to 6 per cent. At the Vale of Leven, the level was almost 30 per cent. The report says that people did not know why that occurred. With due respect to the cabinet secretary, if neither her specialist committee nor her civil servants know the reason, a public inquiry is needed in order that we can understand all the factors and know where we should be going. The Lord Advocate's inquiries will not achieve that.
As other members said, the reports that we have received are helpful. However, they give us neither the full picture nor the full answer. Too many questions have not yet been answered. As I mentioned, the number of deaths at Vale of Leven is not explained. Also, the HPS review was undertaken over only a six-month period. We do not know whether deep cleaning, which both Gordon Brown and the cabinet secretary have ordered, does any good. We need to understand that.
Too many issues remain unanswered. The families are entitled to understand, as far as possible, that all the composite measures that were undertaken by this Administration and the previous Administration, based on the knowledge that we had at the time, were sufficient and will be sufficient going forward if we are to restore public confidence.
All testing and surveillance is not yet standardised, and reporting is not done hospital by hospital. Hugh Henry and Wendy Alexander referred to that. In England, reporting is done by hospital so that if things move in the wrong direction, that can be identified right away. The HPS report now refers to that for the first time, and shows that deaths in the Vale of Leven hospital were above predicted levels in January and March. If a reporting system that indicated that had been in place in March, we would not have had to wait until the Dumbarton and Vale of Leven Reporter invited us to examine the issue.
Some reporting systems are in place, but they are not effective and they are not being used properly. Do we want a hospital-based reporting system? Will that restore confidence? We need to consider that as part of a public inquiry.
HPS issued the C difficile associated disease care bundle only on April 1, but its status was only advisory. The website said only that HPS
"would like to hear from"
people who were using the care bundle. That does not indicate attention to what actually needs to happen. There should have been directives that were independent of inspection and which had teeth.
The cabinet secretary has said repeatedly that the issue is being taken seriously—I do not deny that—but the families and the public do not believe that the Parliament is taking the issue seriously enough. We need a public inquiry to show us the way ahead and to help us to understand what has happened.