Scottish Government
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Response to Vale of Leven Hospital Inquiry

Recommendations accepted to strengthen patient safety in Scotland’s NHS.

Health Secretary Shona Robison has apologised to the patients and families affected by the Vale of Leven outbreak as she accepted all recommendations in the inquiry report.

The public inquiry into deaths related to C.Difficile infection at the Vale of Leven Hospital between 2007/08 was announced by the Scottish Government in 2009.

The inquiry, chaired by Lord MacLean, provides an in-depth explanation of what happened at the Vale of Leven to allow the outbreak to happen.

The Government will accept all 75 recommendations in the report and establish an implementation group to take them forward, with strong input from the families affected.

Ms Robison said:

“Our first thoughts must be with the families and patients who have been let down by our NHS and for that I am truly sorry.

“After the inquiry started Lord MacLean broadened the remit to extend the time period and scope, including patients who died after they left hospital. As a result this report now shows that 34 patients died in the outbreak which began in January 2007. Our NHS failed in its duty of care for all of these patients and their families. As the Cabinet Secretary for Health, that is a matter of deep regret for me, this government and indeed the whole of the health service.

“That is why we will accept all 75 recommendations and go further where we can. As well as creating our implementation group, I am today writing to all health boards to ensure they review their services against the report and respond to the Government within eight weeks.

“Lord MacLean has provided a thorough, definitive and clear explanation of what went wrong at the Vale of Leven in response to the families wholly understandable call for answers.

“While NHS Scotland has moved on significantly in the intervening period, Lord MacLean’s report gives us the further insight to ensure that the NHS does not fail patients and families as it did at the Vale of Leven.

“This report indicates a clear picture of the failings in the system that led to the c.diff outbreak. Its findings outline the lack of investment in the hospital, which was simply no longer fit for its purpose of providing modern health care. There was a lack of managerial oversight and a fundamental breakdown in the links between what was happening at ward level and those in positions of authority at the board.

“Added to this there had been long standing uncertainty over the future of NHS Argyll and Clyde. A merger with NHS Greater Glasgow was announced in 2005 but not effectively implemented until after the outbreak. This allowed bad practice and lack of managerial control at the Vale of Leven.

“At a national level there was no effective inspection regime at the time to pick up these failings and their impact on patient care. We now have an effective inspection routine through the Healthcare Environment Inspectorate that completes unannounced, comprehensive inspections and demands urgent actions. 

“The report highlights those who either abdicated their responsibilities or failed to carry them out effectively. There is no place for this conduct in our NHS, which fell below even the minimum standards we expect. It is for the health board as the employer to consider the implications and we would expect them to consider the report’s findings on this aspect urgently.

“The report found clear failings across all levels in the system – including nursing and medicine through to management.

“We understand that the board are writing to the families to apologise today and offer to meet with them to discuss the findings of the report and the issues it raises. That is the right course of action and we hope it will help resolve remaining concerns they may have.

“Given the findings we need to look closely at how we consistently ensure that we maintain high standards of care 365 days a year.

“We have already announced that Scotland’s Interim Chief Nursing Officer will be working closely with board nurse directors to develop local quality assurance programmes to empower their senior charge nurses to fulfil their role as guardians of quality care.

“I want to go even further and will be asking that information from these quality assurance programmes is publicly available and easily accessible to patients and the public. We will also roll out national standards for nursing documentation and care planning, which will be monitored as part of the quality assurance programme.

"We should also note that c.diff and MRSA levels have reduced to record low levels. Our NHS now responds to infections in a faster, more effective and more visible way. Our Scottish Patient Safety Programme is transforming care, reducing mortality rates by nearly 16 per cent.

“Of course we can do more, and we will use the recommendations to improve systems further – such as creating local infection taskforces and working to give Healthcare Environment Inspectorate the power to close wards.

“We must continue to act decisively and drive long term improvements based on Lord MacLean’s recommendations. That is exactly what we will do, together with NHS Scotland and the families affected by this outbreak.

“Our top priority is that lessons are learned so that what happened at the Vale of Leven can never be allowed to happen again.”

The Scottish Government will carefully consider the full report, working with families, stakeholders and across the Parliament. A full response to the report will be published in Spring 2015.

Notes To Editors

The Vale of Leven Hospital Inquiry was set up out under the Inquiries Act 2005 and the Inquiries (Scotland) Rules 2007.

 

Channel website: http://www.gov.scot/

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