Clostridium Difficile (Vale of Leven Hospital)
The next item of business is a statement by Nicola Sturgeon on Clostridium difficile cases at the Vale of Leven hospital. The cabinet secretary will take questions at the end of her statement and there should therefore be no interventions or interruptions during it.
I begin by conveying my sincere condolences to the families of all those who have died at the Vale of Leven hospital as a result of C difficile. I hope that my statement will assure them—and the other patients who contracted C difficile at the Vale of Leven in the past six months—that the Government takes the issue extremely seriously.
I am deeply concerned that the 54 cases that occurred between December 2007 and 1 June 2008 and the 16 deaths that are included in that figure came to light only as a result of a retrospective investigation by the health board. That raises serious questions about the robustness of both the surveillance systems and the infection control procedures that are in operation at the hospital.
I will outline later in my statement the action that Greater Glasgow and Clyde NHS Board has taken to address those deficiencies and the further action that I propose to take. First, however, I will set out the timeline of events since NHS Greater Glasgow and Clyde became aware of cases of the 027 strain of C difficile.
On 2 May, the national reference laboratory alerted the Vale of Leven hospital to two cases of C difficile, which were identified as the 027 strain. On 21 May, the infection control team became aware that, since August 2007, a total of six cases of the 027 strain had been identified from recent and historical samples across the Clyde area and that three of those had a common link to the Vale of Leven. At its meeting that day, the incident review team set in train a range of actions to improve infection control. Health Protection Scotland and the Scottish Government were informed of the situation and I was subsequently briefed by officials.
On 22 May, NHS Greater Glasgow and Clyde issued a press release confirming its investigation of the three linked cases of 027 and confirming that one of the patients involved had died in March. On 28 May, the infection control team met again to ensure that action to improve infection control at the Vale of Leven was being taken forward. On 6 June, a local Dumbarton newspaper advised me that it intended to report a possible five deaths from C difficile at the Vale of Leven. As I outlined, the infection control team was implementing a range of actions at that time. A review of lab data to establish the number of C difficile cases was also under way.
On 10 June, the Scottish Government was advised by NHS Greater Glasgow and Clyde that, in addition to the other actions that it was taking, a full look-back review had been conducted. That review had identified a total of 54 cases of C difficile infection from December 2007, including eight deaths where C difficile was the main cause of death and another eight cases where it was a secondary cause. The outbreak control team met on 10 June. NHS Greater Glasgow and Clyde updated the public by press release on 11 June. I received an interim report on the situation from NHS Greater Glasgow and Clyde on 13 June and a further report on 17 June.
The reports that I have received from NHS Greater Glasgow and Clyde give serious cause for concern. They suggest that the surveillance systems that were in place at the hospital were inadequate and did not alert the board to the number and pattern of cases. They also make it clear that a physical examination of the hospital by the infection control team identified serious infection control issues. It found that throughout the hospital, in both clinical and patient toilet areas, there was a lack of dedicated hand hygiene basins; many commodes were not fit for use and required to be replaced; personal protective equipment such as gloves and aprons was not readily available; and bed spacing throughout the hospital fell short of health and safety recommendations. The infection control team was also informed that those issues had been raised by staff over a number of years.
The reports also set out a range of actions that the board is taking to address those issues. The actions include stepping up local surveillance systems and infection control procedures throughout the hospital to bring them into line with current NHS Greater Glasgow and Clyde standards; a concerted drive to improve hand hygiene compliance, led by the board's hand hygiene co-ordinator and top-level medical and nursing staff; the opening of an additional ward to improve bed spacing and access to hand-washing facilities; an urgent review of the use of antibiotics that are known to reduce the body's natural defences against C difficile; staff training to highlight awareness of infection control interventions; and a commitment by NHS Greater Glasgow and Clyde to refurbish and upgrade the facilities at the hospital. The board has also invited Health Protection Scotland to review the hospital's infection control procedures to ensure that they meet national standards.
Although I am pleased that those steps have now been taken and pleased to have the board's commitment to the refurbishment and upgrade of facilities at the hospital, it is nevertheless my view that the case for an independent review is overwhelming. The public need to know why the surveillance systems and infection control procedures did not work as they should have done. They are also entitled to assurances that the actions being taken are adequately addressing the key problem areas and do not fall short in any way.
It is also vital to have a thorough investigation to ensure that any good practice recommendations are picked up by other health boards and adopted nationally so that we can reassure patients in other parts of the country that their safety is being protected as fully as possible.
I can therefore announce today that an independent review will be held. It will examine all the circumstances surrounding the 54 C difficile cases, review the adequacy of the surveillance systems and infection control measures that were in place at the Vale of Leven, and review the adequacy of facilities, procedures and systems that are now in place at the hospital.
The review will be led by Professor Cairns Smith, professor of public health at the University of Aberdeen. He will be assisted by Professor Mary Henry, nurse director of NHS National Services Scotland, and Dr Gabby Phillips, a consultant medical microbiologist at Tayside NHS Board. I have asked for a full report and recommendations to be finalised—and made public—by the end of July.
The review is, of course, without prejudice to the statutory responsibilities of the Lord Advocate under the Fatal Accidents and Sudden Deaths Inquiry (Scotland) Act 1976.
The situation at the Vale of Leven raises wider questions about the surveillance of C difficile throughout the national health service. A series of further actions is therefore being taken. First, all infection control managers are being asked to review their own C difficile data over the past six months and to report their findings back to Health Protection Scotland and to the Scottish Government as soon as possible.
Secondly, my officials have contacted all other boards to check on their local surveillance systems to ensure that they are fit for purpose. It is vital that the systems can detect any increase and that we consider linking up surveillance data with data on deaths. Thirdly, Health Protection Scotland, in collaboration with my officials, is preparing new national guidance on C difficile, which will stipulate clear requirements for local surveillance monitoring and ensure consistency of approach. Taken with the results of the review, those further actions will allow us to determine how procedures could and must be improved across Scotland.
I am sure that all members will share my view that the position at the Vale of Leven is deeply concerning. Like all members, I expect the highest standards of surveillance, infection control and care to prevail everywhere in our NHS, and I hope that my statement shows that we are willing to face up to the challenges in delivering those high standards.
The safety of our patients is and must be paramount. A thorough review will take place over the coming weeks to identify the circumstances that led to the situation at the Vale of Leven, and I am determined to ensure that the lessons learned from the exercise will help us to drive C difficile infection rates down and reduce the risks to patients.
The cabinet secretary will now take questions on the issues that were raised in her statement. We have about 20 minutes for questions, after which we move to the next item of business.
I begin by thanking the minister for agreeing to our request for a statement to Parliament. It has revealed serious findings, and it is concerning that they are only beginning to come to light.
On behalf of my party, I also express condolences to all the families involved. We now know the scale of the outbreak: 54 cases and 17 deaths directly connected to C difficile—possibly the most serious outbreak in the United Kingdom. In the interests of the families involved and the need to restore wider public confidence, a robust inquiry, independent of Government, must be of the highest priority.
The cabinet secretary first claimed that she was told about the C difficile outbreak on 10 June. She then had to admit that she actually knew on 6 June. Today, we learn that the minister was briefed on 21 May about six cases and four deaths at the hospital in question. When she was briefed on 21 May, what questions did she ask and what actions did she instruct?
Why did the cabinet secretary take from 21 May until 18 June to advise Parliament, express condolences and determine appropriate action? Those questions are of the highest importance, given the lives that have been lost and the scale and depth of the problems in the hospital.
Did the cabinet secretary or her department receive representations about the need to improve guidance and procedures on C difficile between January and June? In that period, improvements took place in England and I understand that representations were made about the need to improve procedures and guidance.
I acknowledge Margaret Curran's welcome for my statement and for the independent review. I confirm that I was briefed on 21 May on the investigation that NHS Greater Glasgow and Clyde had undertaken into the three cases that had a link to the Vale of Leven hospital. That was what I told the BBC on Sunday. At that time, I was aware of one death. Indeed, in its press release of 22 May, NHS Greater Glasgow and Clyde confirmed that one of those patients died in March. I have always been open about the situation and I hope that Margaret Curran accepts that.
Margaret Curran suggests that I have somehow tried to cover up my knowledge. It is interesting that the revelation on which she bases her claim is a quotation from me in a newspaper. Telling a newspaper something is a rather strange way of covering something up. At no point have I said that last Tuesday was the first time that I knew of a problem with C difficile at the Vale of Leven hospital. I have consistently made it clear that I knew about the problem on 21 May. However, last Tuesday was the date on which the Scottish Government became aware of the findings of the look-back exercise, which confirmed the number of cases and the number of deaths in the past six months.
The Scottish Government takes seriously any representations that are made to it. If Margaret Curran has a particular representation that she wants to draw to my attention, I will be more than happy to confirm with her what action the Scottish Government took.
I agree absolutely that all members of the Parliament have a duty to ask questions. I am happy to have given the statement and to answer questions. However, it is important that we as a Parliament and I as health secretary focus clearly on the key issues: why the deaths were not picked up in the early months of this year and what happened—or, as the case may be, did not happen—in the months or perhaps years before those deaths to ensure adequate surveillance and infection control procedures at the Vale of Leven. Those issues concern me most and are the reasons why I have established an independent review that will examine all the circumstances.
Scottish Conservatives echo the condolences that the health secretary expressed to the relatives of those who have died. I thank her for the advance copy of her statement. Jackson Carlaw and I were shocked by the findings, which are much more serious than we expected.
Were the findings and recommendations of inquiries into C difficile outbreaks in England and Wales distributed to all NHS boards in Scotland? If so, what action was taken as a result?
Given the previous Executive's and the current Government's policies on and priority for infection control, why did the outbreak happen?
How soon will patients know that the local surveillance systems in their NHS board areas are fit for purpose? A serious confidence issue is involved.
We welcome the new guidance that Health Protection Scotland is preparing, but how can we be assured that future surveillance systems and infection control procedures will be adhered to, monitored and audited and that accountability will be provided for?
I share Mary Scanlon's shock at the findings that I have outlined to Parliament. I was certainly shocked when I read the reports that NHS Greater Glasgow and Clyde submitted to me, which is why I became absolutely convinced that it was necessary, in the interests of public confidence, to have a full independent review of all the circumstances surrounding the situation. I hope that all members will welcome the fact that there will be an independent review.
Mary Scanlon asked about the Maidstone report. As she will be aware, that report identified a number of issues to do with leadership, clinical governance, prioritising infection control, and optimising clinical care and the use of antibiotics. Those issues have been closely covered in the work of the health care associated infection task force, which, of course, has been in existence since 2003. Some of the more critical issues relating to organisational structures that are raised in the Maidstone report do not directly apply to Scotland because of our different organisational set-up, but Scottish Government health department officials have mentioned the report on a number of occasions to health boards and key NHS staff groups, and there is wide appreciation of the importance of prudent prescribing, strict hygiene, environmental cleaning, isolation and the cohorting of cases. Indeed, there is wide appreciation of the conclusions of that report. It is important that such awareness continues to be closely monitored.
On the seriousness with which the Government treats infection control, I hope that all members accept that I have made it clear in my time as Cabinet Secretary for Health and Wellbeing that I take infection control seriously. Over the next three years, the Government will invest record sums of money to fight the battle against infection. We are updating the cleaning specification to make it much tougher for hospitals, and we want improved hand hygiene compliance in hospitals. However, as Mary Scanlon said, we must ensure that policies are delivered on the ground, which is why there is now regular monitoring of, and reporting on, such issues. We must ensure that measures are robust.
I agree with what has been said about accountability.
I must ask you to be brief, minister.
I think that I have answered Mary Scanlon's final question.
Thank you. I am grateful to you. We are very tight for time.
I, too, thank the cabinet secretary for the advance copy of her statement. The Liberal Democrats associate ourselves with her condolences to the families that have been affected.
First, I have a point of clarification. In your statement, you referred to seeking advice and assurances from infection control managers about their systems. Given the time that you have known about the incidents that we are discussing, can you confirm that there are no other C difficile cases or clusters of C difficile cases in any other hospital in Scotland?
Secondly, you said that the independent review will examine all the circumstances surrounding the cases in question, which is proper. We accept that. However, do you accept that members are extremely alarmed about the unhelpfulness of Greater Glasgow and Clyde NHS Board's statement, which said that leading microbiologists had said that that there was nothing to be worried about, because greater surveillance had meant that there were more C difficile cases in Scotland? The board has made no attempt to examine the seriousness of the matter. Will the review consider the board's implication that we should be comforted by its procedures? Its approach has been unhelpful.
Finally, will the cabinet secretary find it necessary to associate the report's findings with the health care associated infection task force's delivery plan? It seems to me that the outcomes of the inquiry will have implications for that plan.
Our time is so tight that I do not even have enough time to chide members properly for using the word "you".
Ross Finnie asked about our request to infection control managers to look back at cases. We have asked them to provide, as soon as possible, information for the past six months. Obviously, I will update members if anything arises from that exercise that they require to know.
As Ross Finnie and other members appreciate, there will be C difficile cases in health board areas and hospitals around the country at any given time. Those cases will be investigated as and when they arise.
Ross Finnie mentioned Greater Glasgow and Clyde NHS Board's press statement, on which I agree with him. I do not think that we can be comforted by the action that the board claims to have taken, which is why I decided to set up an independent review. In the interests of public confidence, members of the public need to be assured that action that that board says it has taken has been taken and has been effective.
Finally, Ross Finnie is absolutely correct to say that the outcome of the independent review and any recommendations that flow from it will require to be aligned with the HAI task force delivery plan.
If action had been taken by the health board in January and February, when the problem with C difficile began, it is possible that the outbreak would have been contained. What actions are being taken to ensure that there is a quicker response to C difficile outbreaks by health boards throughout Scotland? The cabinet secretary will know that, in the past, services at the Vale of Leven hospital have been cut. I hope that the health board does not use the problem with C difficile as an excuse for further removals.
I have set up an independent review because we need to examine closely the events and circumstances in January, February and the early months of this year. First, we need to understand why the surveillance system did not operate as it should. Secondly, we need to know why the infection control procedures that we all expect to be in place did not operate as they should. That independent review is necessary and will answer Gil Paterson's questions.
On his question regarding cuts at the Vale of Leven hospital, I am keen not to conflate different issues. There have been no service cuts at the Vale of Leven hospital since I became Cabinet Secretary for Health and Wellbeing. A number of proposals are either on the table or under consideration by NHS Greater Glasgow and Clyde. They will go through the due process and the decisions on them will be mine to make in due course.
I associate myself with Gil Paterson's remarks.
As the constituency MSP, I welcome the minister's statement and her announcement of an independent inquiry. It is important for the relatives of those who have died to get answers.
Is the minister aware of whether Health Protection Scotland advised the Scottish Government of the case of C difficile at the Vale of Leven hospital before 2 May? Similarly, is she aware whether further information was provided on separate occasions in May, before 21 May, about cases of C difficile at the Vale of Leven hospital?
The minister gave the clear impression that she was first aware of the extent of the problem on 10 June. Indeed, her spin doctor was going around emphasising that point. We now know that the Dumbarton and Vale of Leven Reporter told her about the five deaths on 6 June. More seriously, on 21 May, was the minister briefed about the multiple deaths? Her Government certainly knew about them. Six people contracted C difficile, of whom four died and two were hospitalised. We must have answers. If the minister did not know, why did she not?
I have made clear to Jackie Baillie what I was briefed about on 21 May. I take the information that I give to the Parliament incredibly seriously, and I hope that she appreciates that the information that I have given in my statement has been given in absolute good faith.
In its press release of 22 May, NHS Greater Glasgow and Clyde indicated that one patient had died from C difficile. I was briefed after the infection control team meeting on 21 May about the number of cases that had come to the attention of NHS Greater Glasgow and Clyde. The key point was the link to the Vale of Leven hospital, which had been established in the three cases. It was that fact, rather than any unconnected cases from before, that prompted the investigation by the infection control team. That is the key point in the series of events.
Jackie Baillie seems to claim that I tried to give the impression that I found out about the extent of the problem only on 10 June. I listened to the interview that she gave to the BBC before I gave mine. I do not know whether she was able to stay to listen to mine. Had she done so, she would have heard me say clearly on that programme that I had been briefed on the issues on 21 May. The other point of fact that Jackie Baillie and Labour appear to be relying on is a quote that I gave to the Dumbarton and Vale of Leven Reporter on 6 June. With the greatest respect, if I were trying to cover something up, I would not give the facts to the Dumbarton and Vale of Leven Reporter or, indeed, any other newspaper.
I really must insist that questions are extremely short and to the point.
The problems with hand hygiene and general hygiene at the Vale of Leven hospital that the cabinet secretary outlined in her statement are of serious concern. What action is being taken to address those important hygiene issues in hospitals, not only in NHS Greater Glasgow and Clyde but throughout Scotland?
Hand hygiene is critical. One of the many things that has shocked me about the reports that I have received so far from NHS Greater Glasgow and Clyde is the lack of adequate hand hygiene facilities in the hospital. It is essential that action is taken to rectify that.
Hand hygiene is important throughout the NHS in the fight against not only C difficile but other hospital infections, which is why I have indicated that we intend to increase the required compliance with hand hygiene procedures to 90 per cent for all hospitals and NHS boards. However, I expect it to increase even further from that figure, because I want all hospitals to record 100 per cent compliance with hand hygiene protocols.
The reporting system that was put in place in October 2006 was updated in 2007. It requires cases to be notified to Health Protection Scotland, which in turn notifies the Government through a file note, as it did in this case. Does the cabinet secretary agree that the remit for the independent review that she proposed in her statement is insufficiently wide, in that it does not cover notification from the Vale of Leven hospital to the Greater Glasgow and Clyde Health Board infection control committee or Health Protection Scotland? Indeed, it also does not cover any triggers for informing the Government of what action has been taken or could be taken. I give notice to the cabinet secretary that, if she is unable to extend the remit, I will raise the matter in the Health and Sport Committee and seek an investigation of the failures of the reporting systems up the line.
When did the cabinet secretary know about the five deaths that were mentioned in the Dumbarton and Vale of Leven Reporter?
I can answer that last question first. The Dumbarton and Vale of Leven Reporter informed me on 6 June that it intended to report five deaths. Obviously, NHS Greater Glasgow and Clyde confirmed the number of cases and deaths on 10 June after its look-back exercise.
On Richard Simpson's substantive point, I made clear in my statement that I wanted the review to examine all the circumstances of the 54 cases. I am more than happy to consider the points that he has made and can think of no reason why the review could not or should not consider them all. I am more than happy to confirm that to him in writing, if he wishes.
Does the cabinet secretary accept that her statement is the most awkward and appalling one that she has had to make in the past 12 months? Notwithstanding what she has said about hospital infection control, does not what she has unveiled today already demonstrate the most basic lack of ability to implement the most obvious precautions? Does she not feel that Greater Glasgow and Clyde health board has let her and the people down badly? What assurances does she have that similar situations do not exist in other hospitals that are under the board's control?
The facts that I have outlined to the Parliament this afternoon are appalling: I am appalled by them and I have no doubt that every member of the Parliament is equally appalled by them. They reveal failures on the part of NHS Greater Glasgow and Clyde to ensure the adequate operation of procedures, including basic infection control procedures. However, any way in which I am let down is as nothing compared with the fact that patients and their relatives were let down, and I want to take action to ensure that that does not happen again.
In her statement, the minister said that she was asking all infection control managers throughout the country to review their C difficile data for the past six months. Would she consider it prudent to invite them to review their local surveillance systems and infection control procedures at the same time?
I agree, and I think that I said in my statement—I apologise if I did not—that all boards have been asked to review their local surveillance systems as well. We have had some initial responses from boards that suggest to me that we require further guidance to ensure that consistent requirements are in place, which is why I made the comments that I made in my statement.
That brings us to the end of the statement and questions on Clostridium difficile cases at the Vale of Leven hospital. I apologise to members whom I was unable to call.