Meeting of the Parliament

Meeting date: Wednesday, March 27, 2019

Official Report 1093KB pdf

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Royal Infirmary of Edinburgh (Infection Incident)

The first item of business is a statement by Jeane Freeman on the infection incident at the Royal infirmary of Edinburgh. The cabinet secretary will take questions at the end of the statement.

I am grateful for the opportunity to update members on the actions taken by NHS Lothian in response to an infection incident at the Royal infirmary of Edinburgh.

On 19 March, NHS Lothian wrote to all patients who had aortic valve replacement operations in the six-month period between September 2018 and March 2019 to advise them of a low infection risk arising from their surgery. Those precautionary letters, which were sent to 186 patients, were triggered by the following events.

On 19 February, we were advised by Health Protection Scotland, through the normal channels, of a patient who had contracted a mould infection, who had undergone cardiothoracic surgery at the RIE. On 20 February, NHS Lothian established an incident management team to investigate the matter and set the healthcare infection incident assessment tool at red, due to the severity of the illness and public concern.

On 26 February, NHS Lothian followed that by, rightly, instigating a retrospective review of all patients over an 18-month period. From that exercise, 186 patients were identified for whom there was a low infection risk. Measures were put in place to contact those patients by letter and to provide them with contact information to use for any follow-up questions that they had on receipt of that letter. To date, a total of 26 patients who received letters have contacted NHS 24, of which 19 have been passed on to the board for further discussions. Additionally, information has been provided to local general practitioners and cardiologists about symptoms to be aware of and to give guidance on appropriate testing and onward referral, should that be needed.

On the infection itself, three types of mould infection have been identified, which have affected six patients. Sadly, some of those patients have died. No further cases have been identified since November 2018, but I know that the whole chamber will join me in offering our sympathy and condolences to the families and friends affected.

The three types of mould identified are Lichtheimia corymbifera, Exophiala dermatitidis and Aspergillus. None is commonly found in hospitals.

NHS Lothian proactively undertook an extensive investigation of the incident and, as it should, sought the help of Health Protection Scotland, which visited the hospital at the board’s request and is providing comprehensive expert support to it. The detailed investigation is being undertaken by the lead infection control doctor, together with NHS Lothian’s director of operations and its director of technical service. Health Protection Scotland has visited the wards and theatres involved.

A comprehensive question set relating to ventilation within the cardiothoracic theatres was devised by the lead infection control doctor and lead infection control nurse, with some additional questions from Health Protection Scotland. The response to those questions has satisfied the infection control team and the director of facilities that the ventilation within the theatres concerned is operating within the acceptable parameters for air pressure, air changes and air flow, and no concerns are noted relating to filters.

In addition, of course, NHS Lothian has taken the further steps that we would expect it to take to minimise the risk of further infection spread, including additional and specialised cleaning and environmental decontamination with hydrogen peroxide vapour in all relevant wards and theatres, a review of practice, and air and water sampling from both the environment and specialist equipment.

As a precaution, last week, four planned elective surgeries at the hospital were cancelled to allow for additional preventative measures to be implemented. On 26 March, elective operations recommenced in two of the four theatres, subject to the additional preventative work, and the other two theatres will be operational when the additional cleaning and air sampling and other measures have been completed. All patients whose operations were cancelled have now had their operations rescheduled over this week and next week.

I completely understand that this will have been a worrying time for the patients who have been contacted by the board. However, let me repeat that the board was right to undertake a review of cases and to inform the patients whom it identified as a result of that exercise. Those precautionary steps were the right ones to take, as they were designed to minimise risk and to provide a clear pathway for those with concerns to access services as easily and efficiently as possible.

This is the right time for me to say again that, in Scotland, we have learned valuable and wide-ranging lessons from the tragic experience at the Vale of Leven hospital more than a decade ago. It is important to recognise the significant improvements in patient safety that have been made and sustained in those 10 years. Healthcare-associated infection outbreaks are rare and, although it is important to respond when they occur and to recognise that they are of critical importance to the individuals and the families affected, such outbreaks affect a very small proportion of the 1.2 million in-patient and day cases that are treated every year in Scotland.

Following the introduction of the national infection prevention and control manual, the assessment, reporting and escalation of outbreaks is a far more robust process. Infection prevention and control teams undertake active surveillance of certain organisms and, therefore, can identify outbreaks after finding just one or two cases. As part of outbreak investigations, boards undertake active case finding to look for cases retrospectively and prospectively. The current precautionary steps that NHS Lothian is undertaking resulted from an extensive review of the records of thousands of patients who have had many different types of surgery carried out since the beginning of 2015. That demonstrates that NHS Lothian is taking a rigorous approach to ensuring patient safety.

Overall, NHS Lothian has a strong record. Figures published on 12 February this year show that, over the four-year period from January to March 2014 to July to September 2018, the board’s hospital standardised mortality ratio fell by 2 per cent at the Royal infirmary of Edinburgh, by 10.4 per cent at the Western general hospital and by 13.6 per cent at St John’s hospital.

In addition, since 2014, there have been steady reductions in the rates of staphylococcus aureus bloodstream infections and Clostridium difficile infections in NHS Lothian. With regard to infections that are associated with caesarean sections and hip arthroplasty, NHS Lothian’s performance is on a par with that of the rest of Scotland. Since 2007, there has been a 98 per cent decrease in positive results for MRSA from testing, which compares well with the 93 per cent decrease in Scotland overall.

Clearly, we can improve processes to make our hospitals as safe as they can be, which is what the Scottish public have every right to expect. As my colleagues on the Parliament’s Health and Sport Committee noted recently, there are lessons for us to learn from recent incidents in NHS Greater Glasgow and Clyde, particularly about the importance of robust communication between infection prevention and control teams and estate staff. Such communication is particularly important during maintenance or repair work on the NHS Scotland estate, when extra control measures need to be put in place to reduce the risk of infection.

When I updated Parliament on 26 February, I announced that I had commissioned an independent review to look at the design, build,

“commissioning, construction, handover and”

on-going

“maintenance of the Queen Elizabeth university hospital and how such matters contribute to effective infection control.”—[Official Report, 26 February 2019; c 10.]

In order to ensure appropriate membership of the review committee, the independent chairs of the review, Dr Brian Montgomery and Dr Andrew Fraser, have been taking advice from experts on who will be best able to contribute, as well as analysing and reflecting on the work that has been done to date. From that, they will determine the review’s precise remit and the resources and support that will be required. We expect the independent chairs to consult on a draft remit shortly.

In addition, we are strengthening the roles that individual NHS Scotland infection prevention and control team members play and the expert service that they provide. Next week, to provide further reassurance on the efficacy and robustness of our approach, our chief nursing officer will meet board healthcare-associated infection leads to reinforce their responsibilities with regard to infection prevention, emphasising the mandatory surveillance requirements contained in the national infection prevention and control manual and ensuring that boards have local mechanisms in place to implement the manual reliably and sustainably.

I recognise that no patient wants to receive a letter similar to those sent by NHS Lothian last week, but I hope that what I have outlined today provides reassurance that such letters form part of a proactive and precautionary infection control and risk management system here in Scotland. Not all healthcare-associated infections are preventable, but we have dedicated professionals and a rigorous system, focused on limiting and controlling them. The system is alert to potential infection risks and how to assess and manage them and consistently looks to improve.

I thank the cabinet secretary for advance sight of her statement. As a Lothian MSP, I know, from being contacted by concerned constituents and their families, just how hard this has been for people, and I want to start by sending my sympathies to the families and friends of the six patients who have been infected or who have died, as well as to the 186 patients who have been contacted as a precaution.

With regard to moving forward on this, and in the light of the cases that we have seen across NHS Scotland, what plans does the Scottish Government have to review biological infection prevention as part of the patient safety initiative? Will the cabinet secretary also review how the Parliament is kept updated when any cases occur and when there are outbreaks across Scotland such as those that we have seen over the past few months? It is quite clear that public confidence in our NHS estate has recently been shattered. That is an issue that we must all work to address, and I hope that the cabinet secretary will look to take things forward on a cross-party basis.

On the important first part of Mr Briggs’s question, which relates to what more we can do to ensure patient safety and to look at what are unusual infections, I have asked the national clinical director to begin some work on where we can find international information and expertise. I have also asked him to find out whether these infections always existed but were masked by MRSA, C difficile and so on and whether, as we bring down the incidence of those infections—which, it must be recognised, we have done successfully—there will be small outbreaks of these other infections, which are themselves critical because of their impact on patients.

We need to understand the infections better and know more about not just what triggers their occurrence but how we can prevent them. It is a really important point, and, as that work progresses, I will be very happy to ensure that the Health and Sport Committee, as the right place for such information, is kept advised of our progress in what we are doing. As one might expect, looking at those things will take some time, but we will keep that committee up to date.

Mr Briggs’s other point, about keeping Parliament updated, is very fair, too. I have tried to do that, partly by always responding positively to members asking for statements or by initiating such statements myself, sometimes through the Government-initiated question process, and partly by writing to the committee, as appropriate. I am very happy to talk to the spokespeople in the Opposition parties about what more I can usefully do in that regard. If members are content with that, we will organise such a discussion.

I thank the cabinet secretary for advance sight of her statement. On behalf of Scottish Labour, I offer our condolences to the families of the people who died after contracting mould infections at the Royal infirmary of Edinburgh. We also recognise that the situation is very distressing for the staff at the hospital, too.

Unfortunately, though, here we are again. It might be a different hospital in a different city and a different infection, but the outcome is the same. Patients have died, and public confidence continues to dip. The cabinet secretary rightly mentioned the Queen Elizabeth university hospital, as well as the lessons from the Vale of Leven outbreak of 10 years ago. None of us wants to learn of any further tragic outbreaks, no matter how rare they are or how few patients are affected.

What action has the cabinet secretary taken, personally, since taking up her post to ensure that routine monitoring in all our hospitals is as excellent as it can be—in particular, to protect vulnerable patients from potentially fatal infections?

Of course, we all want the minimal number of infection outbreaks in any of our healthcare settings, whether that is the acute setting, in the community or in health and social care. That is my complete focus, and I am sure that that focus is shared by Ms Lennon, Mr Briggs and others. Patient safety is the most important thing for any health secretary to focus on. However, we need to accept that not all healthcare infections are preventable. Some emerge that are resistant to existing medication and other forms of treatment. Although our medical advances are exemplary and are acknowledged globally, there are times when we are playing catch up, given how infections and bugs work to become resistant to antibiotics, for example.

I am happy to set out a full list of my personal involvement for Ms Lennon, but, as she knows, I tasked the previous director general and the current one with making direct contact with directors of estates and working with infection-control leads, and we have regular updates on all the issues that the Parliament is aware of. We have raised the issue with health board chief executives at every meeting with them, and I have raised the issue with the board chairs. We have paid particular attention to the question of maintenance and estates, and we continue to work on that area. Again, we will update the Parliament on that work. The issue is a constant part of my job, because it matters so much.

I thank the cabinet secretary for providing advance sight of her statement. I associate myself and the Scottish Greens with her remarks and offer our sympathy and condolences to the families who have been affected.

Health Protection Scotland says that it is

“essential that lessons are learned from ... outbreaks”.

However, it is not clear what lessons are to be learned in this case.

I have a point for clarification. I think that I heard the cabinet secretary say that none of the moulds are commonly found in hospitals. However, the written statement that she circulated to members in advance says:

“None are not commonly found in hospitals.”

Can she clarify that, in fact, they are unusual moulds and that her oral statement was correct?

The cabinet secretary said in her statement that acceptable parameters were found in the hospital and that preventative work has been undertaken, but she did not say why the moulds were found in an operating theatre, and I wonder whether we know why they were there.

I will correct the written statement, as there is a double negative in it. What I said is correct—the infections are uncommon in hospital environments. That was part of what lay behind my answer to Mr Briggs’s question about what has happened, in which I said that the infections are unusual.

That takes me to the first part of Mr Wightman’s question, which was about what lessons are to be learned from the incident. One lesson is that we need to investigate further. Given that the infections are unusual and are not commonly found in acute settings, why has the incident happened and what is its exact nature? So far, the source has not been identified, which is why, in my statement, I made the point about the ventilation system and the work that has been undertaken on it. When more than one patient has been infected, the normal process that an infection control team goes through to identify the source is to look at where there is commonality in terms of healthcare staff, equipment and location. However, in this case, that approach has not found the source and we are continuing to search for it.

Lessons will include any improvements that can be made to the operating manual. Once we have identified the source, there will be lessons to be learned from that. We must also ensure that all our boards continue to be robust in the application of the national manual, which is why the chief nursing officer is taking the additional action that I outlined in my statement. All of those are continuous lessons. Of course, we have also learned that we need to pay close attention to the quality of the engagement between estates and the maintenance of facilities and infection prevention and control.

We are checking to ensure that all our boards are learning those lessons. There are always lessons to be learned, and we are keen to ensure that that happens. Despite the overall good record on infection prevention and control across the NHS in Scotland, complacency must never be allowed to slip into the system so that we think that we have got the exercise covered. There is always more that we can do.

I associate Liberal Democrat members with the remarks of sympathy to the people who have been affected.

One hundred and eighty-six letters have been sent out, but only 26 patients have proactively contacted NHS Lothian. Is the cabinet secretary confident that everyone has received their letter and understands the risks that are associated with the infections to which they have been exposed?

I understand that the cabinet secretary cannot say what the source of these moulds is, but can she say where they are commonly found? Are they domestic moulds or agricultural moulds? Will that help her in the investigation that follows?

The question of where the moulds are commonly found is part of the investigation that is going on at the moment. That will help us to ascertain where such moulds might be and how they have reached the acute setting.

On the number of people out of the 186 who have responded, I have asked the board to provide me with an assurance that everyone received their letter. I think that there is a fairly straightforward way for it to be sure about that, so I expect the board to return to me with that information. I will be happy to make Mr Cole-Hamilton and other members aware of the information when I have it.

The member asked whether people have received and understood their letters. The “understood” part is difficult, but many of those patients will have continuing appointments with their general practitioner or with the consultant concerned on the issue for which they had the operation in the first place. That is why we made sure that our cardiothoracic consultants—and not just in NHS Lothian, given that some patients who had their procedure in Lothian might have come from another health board—and all GPs are aware of the issue, the symptoms and the systems that have been put in place to assist those 186 patients, so that they can raise the issue if any of those patients comes before them.

I am not sure whether there is more that we could do in that regard, but I will be happy to consider any suggestion.

All the party front benchers have asked a question, but nine more members want to do so. We have six and a half minutes left and there is no more time this afternoon. I ask for very short questions and succinct answers.

Will the cabinet secretary say whether the whistleblowing process at NHS Lothian would have helped with the investigation of the infection incident? Will she provide an update on plans to appoint an independent national whistleblowing officer for NHS Scotland?

I am not sure that the whistleblowing process at NHS Lothian would have assisted the board’s infection control team, which is proactive, as I said, and identified the issue very early on. In other cases, of course, whistleblowing has been of assistance in such matters.

We are currently finalising work with the Scottish Public Services Ombudsman, who will take on the role that the member asked about, to ensure that we are ready. In the next few weeks, I intend to outline a series of measures—most of which members are anticipating—in relation to all the actions that we need to take on whistleblowing and as a result of the review in Highland.

The cabinet secretary said that two operating theatres are still closed. I note that she also said that the procedures that we have been talking about will resume in the next two weeks or so. Have other operations had to be cancelled because the two theatres are down? If she does not have that information, will she say how many operations have been cancelled as a result of the two theatres still being closed?

The total number of operations that have been cancelled as a consequence of the infection is four. As Jeremy Balfour said, all four have been rescheduled for this week and next week.

The two theatres that have yet to reopen will be reopened as soon as the additional work that was done in the first two theatres is completed in the second two theatres and all the other rotas to ensure that elective surgery as well as emergency surgery continue have been redone to accommodate the downtime in those facilities. As soon as we have the date for the reopening of the second two theatres, we will, of course, ensure that members are aware of it.

Can the cabinet secretary confirm that all clinical staff who are responsible for infection control receive on-going training to ensure that they are in line with best practice?

Yes, I can. All Scottish health and social care staff and students have access to the Scottish infection prevention and control education pathway, which is part of their continuous development and learning. It is the job of the board and clinical managers in the board to ensure that everyone keeps their learning up to date.

Are there any plans in place that could pick up invasive fungus-like materials such as Cryptococcus in hospital ventilation systems before patients become infected?

That is part of the work that NHS Greater Glasgow and Clyde is undertaking to try to identify how an infection entered a closed ventilation system, which is what it rightly had. It has produced results that we have discussed previously. Health Facilities Scotland is involved with that board in doing that, and that work will be part of what the independent review will look at. That will include consideration of whether additional preventative measures in the external fabric of a building can be introduced to prevent any infection from pigeon droppings, for example, entering into what should be the safest of all systems inside hospitals.

The cabinet secretary mentioned that the three types of mould are very uncommon in hospitals, and we know that Scotland has a strong record on infection control. How does Scotland benchmark against other countries for infection control? Can any lessons be learned from other countries about such infections?

The 2016 point prevalence survey demonstrated that Scotland has the lowest prevalence of healthcare associated infections in the United Kingdom and Ireland. In the rest of Europe, Scotland compares favourably with France, Italy, Spain, Portugal, Greece and Finland. That is of some assurance.

A three-day conference is beginning in Glasgow today, and the event is the largest of its type. There have been 24 such conferences over 24 years. More than 3,000 delegates are coming together from 70 countries to talk about the international learning that we need to take part in to continuously improve our practice. We are continuously engaged in looking at what more we can learn and what more we can do.

What follow-up support NHS Lothian has provided to the 186 patients and what steps have been taken to ensure that individuals have received the letters?

I have already answered the second part of that question in answering Mr Cole-Hamilton’s question.

On the follow-up, the letter sets out the basis on which the individual has been written to, the low infection risk that they may be subject to and the symptoms that might indicate infection, and it directs them towards NHS 24 and NHS inform in the first instance for answers to any questions that they might have. It also advises them that their GP and their consultant are alert to the matter and that they can contact them. As I outlined in my statement, when individuals make that contact, the board will follow it up. That is the right protocol.

There is a very clear protocol for how patients are advised of such a situation, which should always be in writing; it should never be by telephone, for example. The board has therefore done exactly the right thing, and it is following up when people get in touch with it.

Also, as I explained to Mr Cole-Hamilton, those 186 people will have follow-up appointments with their GP or their consultant; the matter will be raised with them then to make sure that they understood what the letter said and they will be asked about any potential symptoms.

Which health agencies are working together to support NHS Lothian throughout this investigation?

NHS Lothian rightly involved Health Protection Scotland, which is working with it to provide expert advice. HPS has also visited the theatres and the wards concerned.

In addition, NHS Lothian is in touch with those with expertise in the Scottish Government health directorate and it will make use of Health Facilities Scotland in relation to any changes that may need to be made to the infrastructure at the Royal infirmary of Edinburgh once the source of the infection is identified. I stress that, at this point, there is no indication of any changes being required to the internal infrastructure there.

That concludes the statement. My apologies to George Adam and Neil Findlay, as we have run out of time for their questions.