Vale of Leven report reveals serious failings
The Vale of Leven Hospital Inquiry has revealed “serious personal and systemic failures” contributed to the deaths of at least 34 patients from Clostridium difficile infection (CDI).
Lord MacLean, who led the inquiry, also expresses his view in the report published today that the figure of 34 deaths is probably an underestimate as medical records were not available for all of the patients during the period in question.
“Patients at the Vale of Leven Hospital were badly let down by people at different levels of NHS Greater Glasgow and Clyde who were supposed to care for them. There were failures by individuals but the overall responsibility has to rest with the Health Board," he said.
“The Scottish Ministers bear ultimate responsibility for NHS Scotland and, even at the level of the Scottish Government, systems were simply not adequate to tackle effectively a healthcare associated infection like CDI.
“The major lesson to be learned is that what happened at Vale of Leven Hospital to cause such personal suffering should never be allowed to happen again.”
A full copy of the Inquiry report, including identified failings and recommendations, is available here.
Responding to the publication, Labour MSP for Dumbarton, Jackie Baillie, who campaigned alongside patients and families for justice, said it was a day of “mixed emotions” for those who lost loved ones.
“They were vindicated in their call for a public inquiry as the report identified significant failings at every level of the health service and government.
“The C.Diff outbreak at the Vale of Leven Hospital was the worst in the UK due to the high mortality rate. The families deserve nothing less than a full apology from the hospital management, NHS Greater Glasgow and Clyde and the Scottish Government for the mistakes which compromised patient care.
“What happened at the Vale of Leven should never be repeated anywhere in Scotland so it is vital we learn lessons and implement MacLean's recommendations in full."
Scottish Conservative health spokesperson Jackson Carlaw said the report raises some “very tricky questions” for the health board and Scottish Government.
“As health secretary at the time, Nicola Sturgeon will have to explain why the infection control and inspection regimes were so inadequate, and why the Scottish Government wasn’t paying attention to lessons being learned south of the border.
“Many of the recommendations set out will already have been acted upon, and I’m sure NHS staff across Scotland are absolutely committed to an outbreak like this never being repeated,” he said.
Nevertheless, Carlaw said it would be a good time to “redouble” efforts on infection control.
New Health Secretary Shona Robison apologised and said the report shows that NHS Scotland “failed in its duty of care” for the 34 patients who died as a result of the outbreak and their families, adding that as Health Secretary, “that is a matter of deep regret for me, this government and indeed the whole of the health service”.
She said the Scottish Government will accept all of the report’s 75 recommendations and will “go further where we can,” with a full response to the report expected to be published in spring of next year. The full statement from the Scottish Government is available here. Robison will also address the Scottish Parliament later this afternoon.
NHS GGC also offered a “full and unreserved apology” to those affected.
“This was a terrible failure and we profoundly regret it," chairman Andrew Robertson said.
“I can give the firmest of assurances that, as a result of the lessons that have been learned, this could not happen again.”
The full response from NHS GGC has also been published on the Holyrood magazine website.
For background on the inquiry, you can find my report of the C.diff Justice Group’s campaign for justice, here.
My interview with Clinical Director of the Scottish Government’s The Quality Unit, Jason Leitch, on what the tragedy has taught us about patient safety is also available here.