On Monday of this week the findings of an extensive independent review were published which highlighted significant failings in infection prevention and control, governance and risk management at the Queen Elizabeth University Hospital. The review was carried out by a panel of independent external experts led by Professor Mike Stevens. The review was commissioned by the Scottish Government as part of a wider investigation into the ventilation system, water supply and drainage system at the hospital.
Concerns relating to the risks of infection developed after the hospital moved from its old site at Yorkhill to the New Queen Elizabeth Hospital in June 2015. After the hospital was relocated concerns emerged that the hospital water supply was contaminated and that patient safety was at risk.
The independent review involved investigation of 118 episodes of infections contracted by 84 children and young people who were patients of the new hospital. The patients were receiving treatment for cancer, leukaemia and other serious blood diseases. The review panel were tasked with investigating whether these infections were linked to the hospital environment and assessing the implications for patient care.
The review found that the frequency of infections amongst patients in the hospital was higher than would have been expected. It found that there was evidence of clusterings of infections in the hospital which the review panel doubt occurred by chance.
The review panel have been critical of the approach taken to infection prevention and control despite ever growing concerns about the hospital environment. The review panel have also commented that the steps which were taken at the hospital could not just have been to address public confidence, there must have been an acceptance of environmental risk.
It has been determined in this review that a number of the cases investigated were most likely contracted from the hospital environment.
The impact that these hospital acquired infections has had on the patients and their families has been devastating. Children and young people who were already coping with extreme illnesses have had their safety compromised and have suffered additional complications in their care. Many patients who suffered a hospital acquired infection had to have an additional stay in hospital. Patients had to undergo emergency surgery for their central line to be removed, they had to be admitted to intensive care and there were delays to their ongoing treatment. This has undoubtedly caused additional burden and distress to the patients and their families.
Fears of the risk of infection from the hospital environment will have caused patients and their families’ additional stress and anxiety as the consequences of catching bacterial infections can be serious and life threatening.
The independent review has confirmed that two of the children who died after contracting a hospital acquired bacterial infection, did so, in part as a result of their infection.
Despite years of experience in investigating outbreaks of bacterial infections and the rising concerns about the hospital environment, a suitable ongoing system of review and prevention planning was not put in place. The review panel have criticised the communications between the departments of microbiology and infection control and have criticised that there was not a systematic approach taken to environmental sampling.
In light of the failures of the Queen Elizabeth University Hospital, the independent review panel have made 43 recommendations to improve infection prevention and control and patient safety. Amongst their recommendations they have advised that there is a need for an improved system of consistent environmental surveillance and an improved system for water testing.
Independent investigations over the concerns of the deficits in the design, commissioning and maintenance of the hospital buildings and the impact this has had on patients and their care remain ongoing.
Blog by Stephanie Young, Solicitor