NHS Greater Glasgow and Clyde Health Board response to allegations concerning Vale of Leven C.diff outbreak.
Infection-free patients placed into rooms which contain those infected with C.diff
It has already been acknowledged that there were some occasions when it was not possible to isolate patients because of a shortage of single rooms. There are occasions when it is unsafe to put patients into isolation, e.g. if their condition requires continuous observation by clinical staff or if they are at significant risk of falls. In these cases a risk assessment is carried out and these patients may be nursed on a main ward with the strict application of all the principles of isolation nursing applied apart from the placement of the patient in a side room.
Failure by hospital staff/infection control team to alert NHS Greater Glasgow and Clyde health board of the c.diff outbreak in the months of December, January, February, March and April.
The Vale of Leven Hospital was fully compliant with the requirements of the mandatory HPS National Clostridium difficile Surveillance System. However, this national system was designed to monitor trends but not pick up individual outbreaks at the ward and/or hospital level. The system used to identify outbreaks locally was, until May, 2008, a coloured card system which flagged positive cases and was based on a daily visual inspection of the numbers and types of organisms/communicable diseases in each ward area. With the benefit of having seen subsequently the statistical process control charts which track the levels of C.diff infection, we might reasonably have expected an outbreak to have been identified in the first instance in January, 2008 by the local Infection Control Team and ward staff.
Failure to control a senile dementia patient infected with C.diff who repeatedly wandered a ward having physical contact with infection-free patients.
In these circumstances we would expect a patient with senile dementia to be closely supervised to avoid the risk of cross infection to other patients in our care. The nature of senile dementia creates a continual tendency to wander however appropriate practice would be to ensure any symptomatic patient is closely supervised particularly in carrying out hand hygiene and other control of infection practices to minimise the risk to others within the ward environment. This practice has since been reinforced to staff by the Infection Control Team.
An infection-free patient being placed into the old bed of a C.diff infected patient just hours after that infectious patient was moved out of the room.
NHS Greater Glasgow and Clyde has a strict policy for the cleaning of isolations rooms after an infectious patient has been discharged or transferred. This includes using a chlorine based detergent for the cleaning of near patient equipment and this includes beds. Provided this procedure is followed there is no need to delay the admission of the next patient. There is no requirement/recommendation in the scientific literature or national guidance for a time delay after cleaning prior to the next patient being admitted to that area or bed.
An example of one auxiliary having to help an infected patient and an infection-free patient use commodes at the same time.
It is common practice for nurses on wards to have to provide care to both patients with and without infections. If basic infection prevention principles are applied, in this case the appropriate use of personal protective equipment (aprons and gloves) and hand hygiene then the correct barriers are in place to prevent the transmission of infection from one patient to another.
Testimony from anonymous staff who describe the reduction of cleaning hours and the knock-on effect in terms of hospital cleanliness and infection control.
There has been no reduction in the budgeted hours for cleaning in the period from April, 2006 through to September, 2008. The total weekly floor hours figure at April, 2006 was 1370 hours. At January, 2008 it was 1373 hours; and at September, 2008 remains at 1373 hours. In addition, there has been no deterioration in the hospital compliance against the National Cleanliness Audit. The figure throughout the period from December, 2007 to May, 2008 has been maintained consistently above 96% compliance.
Relatives having to wash soiled and contaminated clothing in their own homes without caution or instruction.
We have a policy which describes the advice carers and families should be given if they are taking home their relatives soiled or contaminated laundry. It should be pointed out that with the exception of very heavily soiled laundry, it is appropriate for laundry to be taken home, and laundered and ironed in accordance with the manufacturers instructions, this is in line with our Infection Control Policy. Nursing staff are expected to advise families how to handle such clothing. Unfortunately, at the time of the C.diff incident we did not have written information leaflets that we could hand to families that would help them follow the guidance at home. Updated patient information leaflets which contain clear advice on this matter have now been produced.
Crowded conditions of some of the hospital wards.
The Vale of Leven Hospital was designed and built in the late 1950s and extended and modified during the mid-1960s. The ward accommodation within the hospital met all extant planning regulations for clinical accommodation, including bed spacing, consistent with the regulations in force at the time of construction. Since this time building regulations have been reviewed and modified on numerous occasions and one of the areas where design guidance has changed over this period is the spacing between the beds in a multiple occupancy ward area.
The Vale of Leven at no time had more beds in any clinical area than its design capacity. However, following the accommodation review carried out in early June 2008 it was decided to reduce the bed configuration in a number of the multiple occupancy areas to reduce the risk of HAI, namely increasing the number of wash-hand basins in each clinical area and achieving a slightly higher ratio of separation between the beds.
This work is being taken forward as part of a rolling programme of improvements to the clinical facilities within the Vale of Leven Hospital. It should be noted that these modifications do not apply to all inpatient wards areas, indeed a number of wards do meet the current accepted standards in respect of bed spacing and wash-hand basin provision.
Admissions or transfers to the Vale of Leven from another hospital despite the Vale not being equipped to cope with more patients.
Transfers to the Vale of Leven happen routinely for a number of reasons as part of agreed clinical pathways across Greater Glasgow and Clyde. These transfers are to ensure that patients receive as much care as possible as close to their own homes as possible and are usually for rehabilitation or following completion of a treatment that is not available at the Vale of Leven.
The main reasons for such transfers are:-
- Older people who have had an orthopaedic operation at another hospital and need a longer period in hospital to receive further nursing or Allied Health Professional care.
- Patients who have been considered for, and/or received thrombolysis (clot dissolving treatment) in the Acute Stroke Unit at the Western Infirmary and need a longer period in hospital to receive further nursing or Allied Health Professional care.
- Patients who have been transferred to the Royal Alexandra Hospital for consideration/completion of an emergency surgical intervention, and following that require a further period in hospital.
- Patients who have been admitted to the Royal Alexandra Hospital as an emergency, following current by-pass protocols, and following initial assessment and treatment are medically fit to return to the Vale for the remainder of their care.
There were 189 transfers to the Vale between January and May, 2008 from another hospital within Greater Glasgow and Clyde.167 of these patients were transferred from the Royal Alexandra Hospital to allow the patients to be cared for in their local hospital. Patients are not transferred unless a bed has been identified as available for them.
Repeated and numerous transfers of C.diff-infected patients internally, from ward to ward.
When patients are admitted as emergencies they are first admitted to a receiving Ward: at the Vale of Leven this was Ward 6. Once they have been assessed and a treatment plan agreed they are then moved to another ward. This is standard practice across Scotland. Patients might then move again if their clinical condition requires it, for example:
- They require a single room
- They require a higher level of care
- They require a period of rehabilitation
Patients admitted to the Vale with non-fatal conditions, who subsequently died after contracting C.diff, not having C.diff included on their death certificates.
We clearly cannot discuss individual cases. It is a matter of clinical judgement whether a condition the patient had at the time of their death, or in the preceding period, contributed to their death and therefore if the information should be included on the death certificate. All individual case records and death certificates for those who died were reviewed as an action from the Outbreak Control Team meetings.
Frontline nursing staff at the rank of ward nurse not having been spoken to directly by the Independent Review Team for evidential purposes as part of the review process.
Professor Cairns Smith and his team on the Independent Review panel had full and unrestricted access to interview any NHS staff. The Professor and his team chose whom to interview which included frontline ward nursing staff and infection control nurses. The Health Board ensured anyone they wished to interview was made available.
If the BBC or anyone else is suggesting NHS Greater Glasgow and Clyde in anyway prevented the Review Team from accessing any staff cohort or individual then this would be a very misleading and untrue allegation.
An email from NHS GGC which was circulated amongst all health board heads of department warning staff against talking to the BBC and specifically to myself (Samantha Poling).
Individual staff members received letters at their work from Sam Poling offering the opportunity of an interview as part of a BBC programme.
Individual members of staff telephoned the Director of Communications to say they had received the letters and wondered how best to respond. The Director agreed to respond on their behalf as individuals. The NHS Greater Glasgow and Clyde policy is clear in that any staff approached directly by the media should alert the press office for advice, support or to discuss how best to facilitate media requests.
Corporate Communications had already responded to many media inquiries along the same lines that as the Procurator Fiscal, Crown Office and Strathclyde Police were continuing to consider any appropriate future actions which could include Public Inquiry, FAI or even criminal proceedings that the organization would not be putting anything else into the public domain than already exists "at this time".
It was agreed that the advice that would be on offer in regard to Vale of Leven and the C.diff outbreak that was currently undergoing legal scrutiny should be offered proactively to heads of departments at the Vale of Leven. The advice issued is consistent with statements previously issued to the BBC and other media organisations over recent months.
Testimony from anonymous staff who describe an internal investigation into the outbreak as a 'witch hunt' in which 'fingers were pointed'.
An internal investigation was undertaken by 3 senior managers prior to the external investigation by Professor Smith and his team. The report produced as a result of the internal investigation was given to Professor Smith for consideration.
The process of the investigation involved a number of staff being invited to meet with the 3 managers either on their own or accompanied if they preferred, most chose to be unaccompanied. Everyone was asked a core set of questions, and their responses were recorded.
From that an internal report was produced which highlighted a number of 'learning opportunities' which have now been implemented or are nearing completion. The internal report did not in anyway 'point fingers' at staff members.