Clostridium Difficile (Ninewells Hospital)
Good morning. The first item of business is a statement by Nicola Sturgeon on the Clostridium difficile outbreak at Ninewells hospital. The cabinet secretary will take questions at the end of her statement, so there should be no interruptions or interventions during it.
I begin by conveying my sincere condolences to the families of those patients who died in ward 31 at Ninewells hospital as a result of Clostridium difficile. My statement will set out the detail of the events that led up to and followed the outbreak that has been declared by NHS Tayside. It will provide assurances of the steps that the Government has taken and is taking to ensure that the risk of outbreaks is minimised and that, where they occur, action is taken quickly to ensure that all necessary infection control procedures are in place and are robustly applied.
During the outbreak in ward 31 at Ninewells hospital, eight elderly patients were confirmed as having Clostridium difficile infection. Seven of those patients were confirmed as having the virulent 027 strain; the other patient was found to have the 078 strain. Sadly, five patients have now died. Two of them died as a direct result of Clostridium difficile infection. For the other three, Clostridium difficile was a factor in but not the main cause of death. All five patients died in the period between 21 October and 6 November, not over a 10-week period as was, unfortunately, inaccurately reported in the news release that NHS Tayside issued on Tuesday.
I am advised by NHS Tayside that it kept patients and their relatives fully informed at all times. Rightly, initial action has focused on dealing quickly and effectively with the outbreak. Ward 31 is a 22-bed medicine for the elderly ward. NHS Tayside has confirmed that the trigger that is used for declaring an outbreak in the ward is three confirmed cases of Clostridium difficile within a 30-day period.
Setting control limits on case numbers in clinical areas is standard infection surveillance practice. The control limit that is set is informed by historical data on infection prevalence and patient profile in the ward. I stress that, irrespective of control limits, individual cases of Clostridium difficile, when identified, are appropriately managed through infection prevention and control measures, which include the isolation or cohort care of patients. When control limits are met or breached, further investigations take place to establish whether there are links between individual patient cases, to identify the cause of the outbreak and to establish whether additional infection control measures are needed to contain the risk of infection spreading further.
NHS Tayside has reported that three patients were confirmed as Clostridium difficile ribotype 027 positive on 14, 17 and 18 October. Because that number breached the control limit that had been set for ward 31, an outbreak was declared on 19 October and the ward was immediately closed to all new admissions.
As soon as the outbreak was declared, NHS Tayside undertook retrospective investigations, which confirmed that one patient had been identified as Clostridium difficile ribotype 078 positive on 19 September. The case involved a different strain of the infection, so it is not linked to the three cases that triggered the outbreak. However, it has been included in the overall number of eight cases. One further patient was identified as strain 027 positive on 5 August 2009. Although the case was outwith the 30-day trigger period, the fact that the 027 strain of Clostridium difficile had been identified in patients at the time of and subsequent to the outbreak being declared led NHS Tayside to include it in the outbreak numbers. The working assumption at the moment is that the 027-positive patient concerned may have been the index case for the subsequent outbreak, but investigations by NHS Tayside and Health Protection Scotland into the cause of the outbreak are on-going. The outcome of those investigations will be reported to me.
NHS Tayside has confirmed that three further patients on the ward were identified as ribotype 027 positive on 21, 26 and 30 October. There have been no new cases in ward 31 since 30 October.
My officials were notified of the outbreak on 21 October and alerted me to the situation on 21 October; I have received regular reports from NHS Tayside on developments since then. Health Protection Scotland visited Ninewells hospital on 29 October to review the control measures related to the outbreak of Clostridium difficile in ward 31. It advocated no additional control measures, as those noted by the infection control team as being in place were in line with current national guidance for the management of Clostridium difficile, but made recommendations on next steps in relation to the on-going investigation and management of the outbreak. Those are being implemented with on-going support from Health Protection Scotland.
The new health care environment inspectorate, which was scheduled to visit NHS Tayside on 11 November as part of its programme of visits, visited yesterday and will review infection control systems on ward 31. A deep clean of the ward took place yesterday. I have asked the inspectorate to undertake a follow-up visit as soon as possible.
It is essential that the outcome of the investigations that are being undertaken to assess the infection control systems that are in place in ward 31 and in NHS Tayside as a whole are fully understood and that any gaps in relation to current policy and practice are identified and addressed. It is in no one's interest to speculate at this stage on what the outcome of the work will be, but I assure the families of those who have been so tragically affected that any follow-up action that is needed will be taken swiftly by NHS Tayside and the Government, with, I am sure, the full support of the chamber.
It is inevitable that parallels will be drawn between this outbreak and the tragic situation at the Vale of Leven hospital last year. However, it is important to stress that, whereas the Vale of Leven outbreak, which spanned six wards, affected 55 patients and caused or contributed to the deaths of 18 patients, went unnoticed for a period of several months, the outbreak at Ninewells was identified and responded to quickly by NHS Tayside. Nevertheless, the Ninewells outbreak is evidence of the need to continue and intensify the actions that we have taken since events at the Vale of Leven.
Following the Vale of Leven outbreak, we introduced a range of measures to reduce the risk of harm from infection across NHS Scotland. They included implementation of a national health care associated infection action plan to ensure that boards have the necessary policies and practices in place to drive improvements in key areas of governance, leadership and surveillance; the creation of an independent health care environment inspectorate that will undertake a programme of both announced and unannounced visits to all acute hospitals over the next three years; an additional £5 million of funding to pay for extra domestic staff across the national health service; a new target to reduce C diff in the 65-plus age group by at least 30 per cent by March 2011; extra funding to enhance local HAI surveillance procedures; full roll-out of an MRSA screening programme by January 2010; local reporting on hospital-by-hospital performance on MRSA and C diff rates, hand hygiene, environmental cleaning and the causes of adverse incidents; additional funding for the appointment of antimicrobial pharmacists to ensure the prudent prescribing of antibiotics at ward level; the introduction of a zero-tolerance approach to non-compliance with hand hygiene policies across the NHS; the revamp of the senior charge nurse role, to give such nurses responsibility for ensuring ward cleanliness; and deepening of the cleaning specification and monitoring framework, to ensure the highest possible standards of cleaning across the NHS.
I am acutely aware that none of the measures that I have listed will do anything to negate the impact of what has happened at Ninewells hospital, but it is worth reflecting on the impact that they appear to be beginning to have in NHS Scotland as a whole. The latest figures published by Health Protection Scotland show that the number of cases of C diff in Scotland has reduced by 14 per cent compared with the previous quarter and by 42 per cent compared with the same period in 2008. Rates of C diff are now at their lowest since mandatory surveillance began.
I am under no illusions about the fact that the outbreak at Ninewells reinforces the need for us to keep the fight against hospital infection at the top of our agenda. I have said before and say again that reducing health care associated infection is my top priority and the Government's top health priority. We will continue to ensure that all that needs to be done is done and that lessons continue to be learned, to reduce the risk of harm to both patients and their families.
The cabinet secretary will take questions on issues that were raised in her statement. We have about 20 minutes for questions.
I, too, express my condolences to the families who have lost loved ones in the tragic outbreak of Clostridium difficile at Ninewells hospital.
I thank the cabinet secretary for the advance copy of her statement, but I regret the lack of transparency that has characterised NHS Tayside's handling of the outbreak. The health board claimed that the problems occurred over 10 weeks; the cabinet secretary said that they have occurred over three weeks.
Let us take the cabinet secretary's timeline. Does she agree that patients and their families have a right to know whether there is an outbreak? Why, when cases were identified on 14 October, 17 October and 18 October, was someone apparently admitted to the ward on 19 October, who then went on to contract C difficile and subsequently died? Their family claims that they were not told. Why is the trigger three cases, when it is two cases in other health boards?
We know from the outbreak at the Vale of Leven hospital that the 027 strain is particularly virulent. The mortality rate at the Vale of Leven was 33 per cent, which at the time was the highest in the country. However, at Ninewells, the mortality rate is a staggering 62 per cent. Can the cabinet secretary explain why the mortality rate is so high?
I will try to take Jackie Baillie's questions one by one. First, I reiterate a point that I made in my statement. The reference by NHS Tayside on Tuesday to a 10-week period was wrong. The dates are as I set out in my statement. The error in NHS Tayside's news release on Tuesday was deeply regrettable, and I have stressed to the chairman of the board that accuracy of information relating to C difficile outbreaks or any other infection outbreak is essential. I hope that members will understand that the timeline is as I set it out today.
Jackie Baillie asked about transparency. I make it clear that when outbreaks are identified the absolute priority is to protect patient safety. I know that members will understand that. The initial priority and focus of NHS Tayside was, rightly, on dealing with the outbreak and bringing it under control. Patients and families who were affected were kept fully informed at all times—NHS Tayside has assured me that that is the case.
I make the important point that during the period in question the ward in question was closed to new admissions. Jackie Baillie referred to a case that was reported in the press yesterday of a patient being admitted to Ninewells after the outbreak was declared. I have checked that with NHS Tayside and the information that NHS Tayside has given me is that that patient was admitted to Ninewells hospital on 12 October and was transferred to ward 31 on 13 October. That is the information that I have been given by NHS Tayside.
The triggers for declaring an outbreak rightly vary from ward to ward, because account is taken of the particular circumstances of different wards. Some wards are more prone to C difficile, for example because of the age and vulnerability of patients. Triggers also take into account wards' past experience of C difficile. Therefore, the triggers in some wards will be different from the triggers in other wards. That is standard and recognised infection control and surveillance practice.
Transparency is vital in such cases. I submit to members that there is now greater transparency around C difficile in particular and hospital infection in general than has ever been the case. In addition to the quarterly statistics that are published we now have bi-monthly hospital-by-hospital reporting, which any member of the public can access on the website—this Government introduced that. NHS boards will also, as appropriate, inform members of the public of instances such as this one. I do not intend to be at all political about the matter, but it is the case that for most of the previous Administration we had no idea how many C difficile cases there were, because the information was neither collected nor published. We are now in a better place. It is right that there is transparency, which allows not just NHS boards but me to be held to account. It is right that there is clear accountability.
I also express my condolences to the families.
Ninewells is a first-class teaching hospital, which is highly valued by patients and people in Tayside, Perthshire and Fife.
Has prompt action been taken on a new dress code and on dealing with patients' personal laundry at home, as was promised? Given that the case on 5 August might have been the index case, does the cabinet secretary agree that an electronic bed management and infection control system would have captured the alert more effectively?
Mary Scanlon is right to point out that Ninewells is an excellent acute teaching hospital. I do not want to diminish in any way, shape or form the significance of what has happened at Ninewells hospital during the outbreak, but cases of C difficile in Tayside have fallen by around 25 per cent since 2007. That is not good enough, but it is nevertheless encouraging, and I want that progress to continue.
Hospitals and staff follow guidance on dress code and dealing with laundry. I can make the guidance available to members, for their interest.
Mary Scanlon, Jackson Carlaw and other members on the Conservative benches have pursued electronic bed management and I am grateful to them for doing so. As they know, we are piloting different approaches to electronic bed management in NHS boards around the country. We will fully evaluate the pilots and take whatever action we consider appropriate, in full discussion with the Conservatives and other members. I am grateful to Mary Scanlon and her colleagues for continuing to pursue what is an important issue.
I thank the cabinet secretary for the advance copy of her statement. I associate the Liberal Democrats with the condolences that have been expressed to the families of the patients who died at Ninewells.
I hope that the cabinet secretary agrees that public inquiries have a number of roles, not least of which is to establish the facts and make recommendations. A public inquiry can play an important role in re-establishing public confidence. In light of the further outbreak of C difficile, will the cabinet secretary reconsider the remit of the inquiry that is currently being conducted by Lord MacLean? Will the cabinet secretary meet Lord MacLean to consider amendments to the inquiry's remit, so that when the inquiry's recommendations are published it will be clear to the public that the examination had the opportunity to take evidence on all cases and—just as important—that the inquiry has been able independently to verify that the 12 measures that the cabinet secretary identified in her statement are, in its view, adequate and sufficient to meet needs, not just in the Vale of Leven hospital but in all hospitals in Scotland?
Ross Finnie asked an important question. I established the public inquiry into the situation at the Vale of Leven hospital. Members supported that action, which was the right action to take. Ross Finnie knows that the inquiry's terms of reference, in particular term of reference F, were deliberately drawn widely enough not to fetter Lord MacLean's ability to consider whatever cases of C difficile he wants to consider. I mentioned the on-going investigations into events at Ninewells hospital, and I will reflect further when I know the outcome of those investigations.
As I said to Mary Scanlon, nobody—least of all me—should diminish the seriousness of what happened at Ninewells hospital. However, as I said in my statement, it is important not to lose sight of key differences between the outbreak at Ninewells and other recent outbreaks and the tragic and completely indefensible series of events at the Vale of Leven hospital. At the heart of what went wrong at the Vale of Leven hospital was an outbreak that went unnoticed and unidentified and was therefore allowed to run amok through six wards in that hospital. That affected more than 50 patients and caused or contributed to the death of 18. That situation was significantly different.
That said, it is important to learn lessons of every outbreak. Lord MacLean has the freedom to consider whatever cases he wants to. I will of course continue to reflect as we receive the outcome of the investigations that I have spoken about.
We come to open questions. Eight members seek to ask questions. If we are to fit them all in, questions and answers must be relatively brief.
First, I give my condolences to the families of those who died in Ninewells hospital, which is in my constituency.
I welcome the news that the health care environment inspectorate is reviewing procedures. It would be useful to know the timetable for receiving feedback from that.
Will the cabinet secretary take a minute to help patients and potential patients to understand how, despite improving hand and ward hygiene, such bacteria can still infect patients in hospitals around the globe?
Joe FitzPatrick asks a pertinent question. We are right to talk about the progress that has been made throughout Scotland to reduce C diff rates. It is not good enough—much progress has still to be made—but C diff rates have reduced by 42 per cent, as I said in my statement. Nevertheless, outbreaks such as the one that which we are discussing still occur. In the NHS in Scotland—as in every health care system around the world, I suspect—we have not yet eradicated infections such as C diff from hospitals. I hope that we can achieve that but, in the meantime, we must ensure that when an infection such as C diff gets into a hospital, it is controlled and the chances of its onward spread are minimised.
It is clear that NHS Tayside was not successful enough in controlling C diff in Ninewells, because eight patients contracted the infection and—sadly—five of them died from that, as we know. Nevertheless, the board took prompt action to stop the infection's further spread. Our efforts must focus on continuing to improve all the infection control practices that we know minimise the chances of spread.
Ross Finnie referred to the action that I outlined in my statement, all of which is designed to ensure that the action that is taken in the event of a C diff outbreak or any other infection in a hospital minimises spread. We will continue to implement actions and learn lessons so that NHS boards can minimise spread successfully and effectively.
The cabinet secretary repeated clearly that health care acquired infection is the top priority of her and her Government, yet we have another incident that involves the most lethal ribotype—027. Is she comfortable that HPS, the national agency, took 10 days to turn up at the hospital to give support and advice? Will she confirm now or later that, from 17 October, when the first 027 case was typed, a sample from every symptomatic patient in the hospital was sent for typing?
I will write to Richard Simpson about his last question, because I want to ensure that I answer him fully and accurately.
I will be frank with Richard Simpson and all members. Whenever an outbreak occurs, it is incumbent on me that I do not just defend the NHS board's actions; I must critically review all those actions. I did that in this case and I will continue to do that as the outcome of the continuing investigations becomes known.
On the basis of what I know, I am satisfied that NHS Tayside acted quickly and responded effectively once the outbreak had been identified and declared. However, we will always look to learn lessons to ensure that we can operate better in the future. I give that assurance openly to Richard Simpson and every member. I will write to him on the detail of his last question.
We all know that C diff is a worldwide scourge. The cabinet secretary has taken the matter extremely seriously—her record speaks for itself, as C diff rates have reduced by 25 per cent in Tayside since 2007, which is good news in some ways. Is there any prospect of further reducing rates? What methods can we use to achieve that? Can we knock the infection out of Scottish hospitals altogether?
As I said in response to an earlier question, we have not eradicated C diff or other infections from our hospitals. I am not aware of any health care system in the world that has done so. Can we do that? I would certainly like to think so, but experts tell me that that is unlikely, because when we are on top of one infection, another strain or infection will appear—that is in the nature of infection.
We should never ease our efforts to cut down the opportunities for infections to take root in hospitals and we should certainly work hard on an on-going basis—we will never be able to say, "Job done"—to ensure that when infections appear in hospitals, we minimise the chance of spread. All the actions that the Government has taken are designed to do that, but we will not rest on our laurels. A 42 per cent reduction throughout the country and a 25 per cent reduction in Tayside are good but, as I have said several times this morning, not good enough. We will continue to place as much priority as possible on reducing the numbers further.
The cabinet secretary referred to the revamp of the role of senior charge nurses and their new responsibility for ensuring ward cleanliness. What is the status of that programme in the affected ward at Ninewells and at the hospital in general?
As Jackson Carlaw knows, the senior charge nurse programme is being rolled out throughout the country. I will write to him about the programme's precise status, not just in ward 31, but in all wards in NHS Tayside.
The programme is important. Mary Scanlon has suggested in the past that we should reintroduce matrons in hospital wards. In many respects, the revamped senior charge nurse role is analogous to the role that the matron used to play, although that term is not used. The aim is to ensure that wards have clear clinical leadership and that the senior nurses who are on duty in a ward at any time have clear power and responsibility to ensure that certain tasks are done. For example, if a ward does not reach the cleanliness and hygiene standards that it is expected to meet, that can be acted on. That is the right direction in which to go and we should continue to roll out the programme and to ensure that senior charge nurses have the authority that patients want them to have.
I am anxious for people in Tayside to be reassured about the safety of all the wards in Ninewells hospital, so I ask for further details on the deepening of the cleaning specification to which the cabinet secretary referred.
Will the cabinet secretary make it clear that the blame does not lie at the door of hospital domestics? We know that funds were made available in April for 45 extra cleaners, but if they do not have the appropriate equipment, they will not be effective. They need mops and disinfectant, not just the washing detergent that they are reported to have received.
Briefly, please.
It is now reported that stronger disinfectant is to be used. What is used at the moment?
My response to Marlyn Glen's question about blame is that I am not interested in a blame game about C difficile. Everybody who works in the NHS has a part to play in taking all the right steps to ensure that we bear down on infection rates. I accept openly that the buck ultimately stops with me and I will never shirk from that responsibility. It is my job to ensure that health boards ensure that all staff—whether they are domestic cleaning staff, nurses or other NHS staff—have the right equipment in the broadest sense of the word to do the job effectively.
Deepening the cleaning specification was one action that we took following the Vale of Leven outbreak. As Marlyn Glen knows, when boards' performance is monitored against the cleaning specification, boards generally score highly. I was concerned to ensure that the specification and therefore the monitoring against it were as stringent as possible, so we examined the specification afresh to ensure that it was tougher than it had been and that boards had to achieve higher standards to get pass marks.
We will continue to keep that under review, but we have also introduced an extra, important layer—the health care environment inspectorate—because one of the other criticisms that have been made is that too much of the monitoring in hospitals is based on self-assessment and self-reporting. The health care environment inspectorate is intended to take an independent view. Its announced and unannounced visits are important and will be able to assure us all that the right things happen in practice. The inspectorate's first report, which was on NHS Forth Valley, was issued earlier this week, as Marlyn Glen will be aware. Anybody who reads that report will be encouraged that the process will be robust and will lead to improvements.
In my statement I mentioned a deep clean of ward 31. That is under way today. Because the process is different from that used previously—it is a steam cleaning process—the deep clean had to wait until all patients were out of the ward, which happened yesterday. That is why the deep clean had to wait until today.
NHS boards must continue to ensure that every aspect of their cleaning regimes is absolutely up to scratch.
From now on, I am taking time out of the next debate, so I ask that questions and answers be kept brief.
Will the cabinet secretary confirm that the crucial information and facts from yesterday's inspection of Ninewells will be shared with other health authorities? Will she give us an indication of the level of specialist training for the extra domestic staff that she mentioned?
The outcome of all the investigations that I mentioned will be published, as will all the health care environment inspectorate's reports, like this week's report. That is important not only so that other health boards and hospitals throughout the country can learn lessons but so that there is a level of scrutiny by the public, which can be a powerful driver to force change through the system.
It is vital that all cleaners and other domestic staff be given the right training and the right equipment to do their jobs. Jamie Stone will be aware of the cleanliness champions programme, which is designed to ensure that staff across the NHS get the training that allows them to ensure that cleanliness procedures are properly implemented and ensures that they know what the appropriate procedures are.
The cabinet secretary and others may not have heard the Grampian news on Tuesday, when it was reported:
"experts say that NHS Tayside has done all it can to contain this outbreak."
Professor Hugh Pennington said:
"They've taken this very seriously. They've closed a ward. There haven't been any more cases for 10 days—that's good news."
Would it not be more helpful if the Labour Party listened to its own adviser and recognised the good work of all staff instead of criticising in the media all those in NHS Tayside who have done all that they can to contain the outbreak and fight what Professor Pennington calls
"a very cunning and subtle adversary"?
I said in my statement that NHS Tayside has reacted appropriately in responding to the outbreak. I understand that Hugh Pennington offered the same opinion earlier this week when he reflected on the fact that NHS Tayside had taken the situation seriously. That is important, because it is essential that, when outbreaks are identified, quick and effective action is taken. That does not diminish my regret and anger that outbreaks happen at all. We must continue to do what we do and, as we learn lessons from the outbreaks, do more to minimise the chances of them happening in the first place. I assure members, as I have before, that we will continue to do that. I have already commented on the difficulty of eradicating C diff and other infections from our hospitals, but we must continue to work to reduce the chances of outbreaks as well as ensuring that, when they are identified, we minimise the spread as effectively as possible.
Given the gravity of the situation, will the cabinet secretary do more than reflect on the remit of Lord MacLean's public inquiry? Will she direct and require the inquiry to embrace all the outbreaks in Scotland? There have now been outbreaks in Orkney, Elgin and Aberdeen to name a few. That is a tragic situation for us all and we urge her to direct, not simply reflect.
Although Helen Eadie and all other members are right to scrutinise and, if appropriate, criticise the Government's and NHS Tayside's action, I hope that they are under no illusion about how seriously I take outbreaks of C difficile. As I said to Ross Finnie, I deliberately drew the terms of reference for the Vale of Leven inquiry broadly, in consultation with Lord MacLean, in order not to fetter his and the inquiry's freedom to consider cases other than that outbreak. However, in doing that, it was important that I did not move attention away from the Vale of Leven outbreak because, as I have said already, it was not only an outbreak of C difficile but one that went completely unidentified and unnoticed. That is what led to the scale of the problem at that hospital, and it is in the interest of all those who were affected that the inquiry focuses properly on that. However, it is also right that other examples be taken into account, which is why the terms of reference are framed in the way that they are.
As I said, I will reflect carefully and, if appropriate, report back to the Parliament on the results of the investigations into what went wrong at Ninewells. I will not shirk from taking whatever action I consider necessary.