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Independent Review of
Clostridium difficile Associated Diseaseat the
Vale of Leven Hospitalfrom December 2007 to June 2008
w w w . s c o t l a n d . g o v . u k
© Crown copyright 2008
This document is also available on the Scottish Government website:www.scotland.gov.uk
RR Donnelley B57209 8/08
Further copies are available fromBlackwell’s Bookshop53 South BridgeEdinburghEH1 1YS
Telephone orders and enquiries0131 622 8283 or 0131 622 8258
Fax orders0131 557 8149
Email [email protected]
The Scottish Government, Edinburgh 2008
Independent Review of
Clostridium difficile Associated Diseaseat the
Vale of Leven Hospitalfrom December 2007 to June 2008
© Crown copyright 2008
ISBN: 978-0-7559-5854-2
The Scottish GovernmentSt Andrew’s HouseEdinburghEH1 3DG
Produced for the Scottish Government by RR Donnelley B57209 8/08
Published by the Scottish Government, August, 2008
Further copies are available fromBlackwell’s Bookshop53 South BridgeEdinburghEH1 1YS
The text pages of this document are printed on recycled paper and are 100% recyclable
Foreword
The Cabinet Secretary announced the Independent Review of the cases of C.difficile
associated disease (CDAD) at the Vale of Leven Hospital on 18 June 2008. The
Independent Review Team (IRT) met and was briefed on 26 June 2008 with a remit
to report by 31 July 2008. This was a relatively short timeframe, particularly given it
was during the peak summer holiday period, but was necessary given the
seriousness of the events at Vale of Leven Hospital over the six month period from
December 2007 to June 2008. The IRT requested and reviewed a large number of
documents including reports, audits, inspections, data and minutes requested from
the Vale of Leven Hospital and NHS Greater Glasgow and Clyde. The IRT also
visited the Vale of Leven Hospital on 5 occasions during which many interviews were
conducted with staff responsible for a wide range of relevant functions. The IRT is
grateful to NHS Greater Glasgow and Clyde for the prompt way in which all
requested documents were made available and for its openness during the interview
process.
The IRT would like to acknowledge the valuable contribution made by patients and
their families to the review. Many patients and families wrote to the IRT in response
to an open invitation in the local media and then met with members of the IRT over a
two day period. The IRT appreciated how difficult it was for families to describe in
detail their experiences over the past 6 months. Their attitude was positive and
constructive in wanting to ensure that other families did not have to go through the
same experiences. The patients and their families have made a vital contribution to
the Review in identifying the problems and they can also play a part in implementing
the recommendations.
The IRT would like to acknowledge the expert input to the Review process of
Nursing Advisor, Jane Walker on secondment from NHS Tayside and to Cheryl Paris
who provided administrative support.
Mary Henry Gabby Phillips Cairns Smith 31st July 2008
3
Executive Summary
The Cabinet Secretary announced an Independent Review of the cases of CDAD at
the Vale of Leven Hospital on 18 June 2008. An IRT of three with complementary
expertise in public health, epidemiology, microbiology, and infection control was
appointed. The IRT met and was briefed on 26 June 2008 with a remit to report by
31 July 2008. The IRT focussed on the specified remit because of the relatively
short timeframe.
The IRT requested and reviewed relevant documentation regarding the cases of
CDAD at the Vale of Leven Hospital over the six month period from December 2007
to June 2008 and the circumstances contributing to these cases. The IRT also
visited the Vale of Leven Hospital on 5 occasions and interviewed a wide range of
staff from the Hospital and from NHS Greater Glasgow and Clyde. An open
invitation was made through the local press for patients and their families to submit
written and oral evidence to the review and meetings were held with representatives
from 10 families.
It is important that the events at the Vale of Leven Hospital are seen in the context of
an increasing problem affecting hospitals across Scotland where C.difficile has either
caused or contributed to many deaths. Increased cases of C.difficile during periods
of high norovirus activity (which was apparent in the Vale of Leven Hospital over the
relevant time period) have also been noted though the exact relationship is unclear.
The majority of the isolates that were typed were of the 027 ribotype. About one
third of cases were symptomatic at or immediately after admission to the hospital.
The organisation of infection control and the antibiotic policies at the Vale of Leven
Hospital were in the process of being integrated into NHS Greater Glasgow and
Clyde.
The Vale of Leven Hospital has been under threat of closure for more than 10 years.
Uncertainties over the longer term future of the hospital had led to lack of investment
in the upgrading and maintenance of the hospital. In addition the hospital site
appeared to be given a lower priority than other sites in the implementation of
policies, surveillance systems and staff development.
4
The facilities at the Vale of Leven Hospital were inadequate for effective patient
isolation and infection control, and there were frequent patient transfers between
wards and other hospitals during this period.
The death rate associated with CDAD as recorded on death certificates during this
period was higher than expected. Further analysis of the death rate is required and
this is ongoing as part of a separate exercise being undertaken by NHS Greater
Glasgow & Clyde and Health Protection Scotland. Contributory factors may include
co-morbidity in patients treated at the hospital and the 027 ribotype which has been
reported to be associated with more severe disease.
The alert condition system for identification of patients with diarrhoea, with
subsequent stool testing for the C.difficile toxin and isolation of patients with the
infection was operational at the Vale of Leven Hospital over this 6 month period.
There was no system for analysing the rates of new positives to identify when these
exceeded control limits. The transition in the organisation of infection control at the
time resulted in a lack of leadership and supervision, clarity of roles and
responsibilities, and inconsistent infection control and isolation practices was
reported by the families.
The facilities were inadequate in terms of hand washing facilities, single room
accommodation with sufficient toilets, appropriate spacing between beds, clinical and
storage space to facilitate effective infection control practices. There was no active
monitoring of the implementation of antibiotic policies or feedback on usage to
clinical staff.
NHS Greater Glasgow and Clyde introduced a new surveillance system to the Vale
of Leven Hospital in April 2008, a new antibiotic policy in June 2008 and have
restructured their infection control from 1 July 2008. They have also started a 20-
week renovation programme to bring the facilities up to a basic minimum standard
for infection control. Specific actions are recommended as a matter of urgency to
NHS Greater Glasgow and Clyde regarding infection control and antimicrobial
policies, the governance of infection control, the development of clinical leadership to
5
Board level, improvements to patient communication, maintenance of a safe
environment and death certification practices.
The IRT further recommends that there is another independent review visit
conducted at the end of 2008 along with representatives of the patients and their
families to ensure that all the recommendations have been implemented and that
robust systems are in place.
6
Introduction
On 18 June 2007 Nicola Sturgeon, Deputy First Minister and Cabinet Secretary for
Health and Wellbeing announced in Parliament an independent review of procedures
in place at the Vale of Leven Hospital over the period December 2007 to 1 June
2008, in response to information that 55 patients had developed Clostridium difficile
Associated Disease (CDAD), 18 of whom had died of the infection.
Professor Cairns Smith, OBE, Professor of Public Health, University of Aberdeen
was appointed to lead the review and was joined by Dr Gabby Phillips, Medical
Microbiologist, NHS Tayside and Professor Mary Henry, OBE, Nurse Director at
NHS National Services Scotland.
The remit of the review was as follows:
Having regard to the circumstances where C.difficile either caused or contributed to
the deaths of 18 patients at the Vale of Leven Hospital during 1 December 2007 to 1
June 2008, to review (a) the adequacy of the surveillance systems at the hospital
during this period (b) the adequacy of infection control procedures at the hospital
during this period, (c) the adequacy of current surveillance and infection control
arrangements, (d) the adequacy of relevant facilities to prevent and contain C.difficile
at the hospital, such as the availability of hand hygiene facilities, e) what notifications
were given by the Vale of Leven Hospital to NHS Greater Glasgow and Clyde Health
Board Infection Control Committee and Health Protection Scotland, f) what
procedures were followed for informing the Scottish Government of what action has
been taken or could be taken, and to make recommendations about the procedures
and systems that should be adopted at the hospital so that good infection prevention
and control procedures are in place.
In addition to the above remit the Cabinet Secretary for Health and Wellbeing also
made clear her intention for the IRT to involve patients and relatives of patients who
had been affected by the cases of C.difficile at the Vale of Leven Hospital, with a
7
deadline to report to the Cabinet Secretary for Health and Wellbeing by 31 July
2008.
Process
The IRT identified key individuals within NHS Greater Glasgow and Clyde who had
been involved in the management of the cases of CDAD from December 2007 to 1st
June 2008. Each of these individuals was interviewed either in face to face meetings
or, for a very small number, over the telephone. A list of those interviewed is
included at Annex A.
The IRT requested and reviewed a large number of documents including reports,
audits, inspections, data and minutes requested from the Vale of Leven Hospital and
NHS Greater Glasgow and Clyde.
The IRT visited the Vale of Leven Hospital on 5 occasions throughout July. During
one of these visits the IRT members carried out a ‘walk round’ of those wards which
had been affected by the outbreak and of one ward which had not.
After much consideration on how to appropriately and sensitively contact patients
and relatives it was decided that a newspaper advert, submitted to 3 local
newspapers, calling for written evidence from patients and relatives would be the
most appropriate means of contact. This would allow those who wished to contact
the IRT to do so but would not pressurise patients and relatives who did not want to
be involved in the review process. Following the written evidence submitted by
members of the public the IRT met with representatives of 10 families to discuss
their experience.
Background
From December 2007 to 1 June 2008, 55 patients were diagnosed as having CDAD
at the Vale of Leven Hospital. Of these 55 patients, 18 patients died either as a
direct result of CDAD or where it was recorded on their death certificate that the
infection was a contributory factor to their death. The IRT understands that a high
8
proportion of the strains isolated from the infected patients were of the O27 ribotype.
Studies from other hospitals have suggested that this type of C.difficile may behave
differently to other types in terms of survival in the environment, virulence (the ability
to cause disease and also severity of disease), or the ability to spread. Around one
third of the cases at the Vale of Leven Hospital during this period were symptomatic
on admission or within 48 hours of admission. The Health Protection Scotland
publication (7 August 2008) “Report on the Review of Clostridium difficile Associated
Disease Cases and Mortality in all Acute Hospitals from December 2007 to May
2008 reports that “The overall case fatality rate and the case fatality rate with CDAD
with the underlying cause identifies one hospital, Vale of Leven Hospital with excess
deaths” However, the rates of CDAD at the Vale of Leven Hospital were not
statistically and significantly higher than the rest of Scotland during that period.
Meeting with Patients and Relatives
Following a call for evidence from patients and relatives of those affected, the IRT
was extremely pleased to receive a high number of very detailed and informative
responses. A series of meetings with representatives from 10 families allowed the
IRT to discuss and understand the issues which had been faced by patients and
relatives throughout the 6 month period in question. It was appreciated that this was
a very emotional experience for many and the time taken to meet with the IRT was
very much appreciated.
Most patients and relatives interviewed by the IRT commented that they were
generally satisfied with the level of care they and their relative received whilst in the
Vale of Leven Hospital and appreciated that staff were hard working and caring.
The majority of patients and relatives had read about CDAD in local newspapers or
had accessed information from web sites and were previously unaware of the
seriousness of the condition.
Whilst the majority had received information leaflets from the hospital about CDAD
infection control measures, it was felt that it would have been more helpful to have
had an opportunity to discuss any issues/questions further with nurses or medical
9
staff in confidence to increase their own understanding of the infection and raise any
particular concerns. Little or no information or advice was provided on washing
patients’ laundry, only one ward recommended that hospital nightwear be used.
During the course of the review the IRT was made aware of a great deal of work on
the best means of communicating with patients and relatives about C.difficile, which
has been carried out in a nearby hospital (RAH) and which if shared and developed
would be helpful.
Many patients moved to several different wards during their time in hospital, it was
observed that knowledge of infection appeared to vary from ward to ward, on
occasions C.difficile was referred to as a ‘wee bug’. This resulted in mixed
messages and inconsistent advice for relatives. Those we spoke to were very clear
that they should have been told the full facts about the infection.
Most staff were observed using alcohol hand gel and on some occasions visitors
were encouraged to do so, however, this was rarely supervised and consequently
many visitors did not undertake this precaution. There was an apparent lack of
knowledge by some staff that soap and water rather than alcohol gel is required to
prevent the spread of C.difficile.
Instructions for visitors regarding the use of aprons, gloves, touching patients etc.
were unclear and vague and depended on the member of staff on duty at the time.
Nearly all of those who spoke with the IRT commented on the fact that uniforms
were worn outside the hospital as staff went to and from their workplace and thought
that this practice should be stopped. It was observed that some staff left their coats
and bags in the patient’s day room and the availability of cloakrooms was
questioned.
There were many comments on the limited bed space and the close proximity of
other patients, resulting in a lack of privacy and difficulty getting chairs situated at the
bedside during visiting.
10
Poor ventilation resulted in the use of fans and this was questioned given the nature
of the spread of this spore forming bacterium.
The majority of patients and relatives valued the care provided at the hospital which
it was stated had served the community well for many years, however all commented
on the lack investment in the fabric of the building and the impression was that it was
being run down.
Despite the fact that the standard of cleaning appeared to be good most of the time,
the general environment was shabby in appearance giving the impression that it was
not clean. Some bed bays were cluttered with boxes and stores resulting in reduced
ward space and difficulty accessing patient lockers.
The lack and poor siting of wash hand basins was noted, particularly, as these were
not available in every toilet or bed bay or single room.
There was a general expression that the poor state of the building and general
appearance of disrepair was reflected in the low moral of many who worked there.
Throughout the discussions, patients and relatives highlighted a number of
recommendations which they felt would improve services at the Vale of Leven
Hospital and would also help to reach their aim of ensuring that no-one else would
encounter the same issues which they had.
These were:
• Better communication to improve the understanding about C.difficile
• Improved communication about infection control procedures for visitors,
including laundry management
• More easily accessible wash hand basins
• More investment in the fabric of the hospital
• On-going infection control training for ALL hospital staff
• More education about antibiotic use
11
• Improved surveillance both locally and nationally and a national alert system
set up
• Staff should not wear their uniforms outside the hospital
Addressing the remit
The IRT was set a very specific remit by the Cabinet Secretary which is detailed at
the beginning of this report. The response to this remit is detailed below.
a) Examine all the circumstances surrounding the cases of C.difficile at Vale of Leven Hospital during 1st December 2007 to 1st June 2008
The cases of CDAD at the Vale of Leven Hospital must be seen in the context of its
increasing national and international incidence including very large outbreaks in
hospitals in England, the Netherlands and Canada. During December and January,
in common with other areas in Scotland, the Vale of Leven Hospital was
experiencing a number of outbreaks of norovirus which resulted in a number of ward
closures. It is documented that during norovirus outbreaks increased numbers of
C.difficile infections may also be seen (Health Protection Scotland Weekly Report 2
July 2008). Around one third of the cases at the Vale of Leven Hospital during this
period were symptomatic on admission or within 48 hours of admission.
A number of deaths related to CDAD were identified by the local community and
highlighted through local newspapers. Death rates reported elsewhere vary by the
severity of co-morbidities and the length of follow-up, and have been shown to be
higher with the 027 ribotype. In hospital outbreaks, mortality rates at one year of up
to 37% have been reported compared to 21% in control patients matched for age,
sex, comorbidity and length of stay. (Canadian Medical association Journal
2005;173:1037-42). Of the 55 patients at the Vale of Leven Hospital, 18 patients died
either as a direct result of CDAD or where it was recorded on their death certificate
that the infection was a contributory factor to their death. The death rate associated
with CDAD as recorded on death certificates during this period was thus higher than
12
expected. Further analysis of the death rate is required and is ongoing as part of a
separate exercise being undertaken by the Board and Health Protection Scotland.
Contributory factors may include co-morbidity in patients treated at the hospital and
the 027 ribotype which has been reported to be associated with more severe
disease. Full details of the outbreak will be produced by the Outbreak Control Team
in due course.
The Vale of Leven Hospital was previously managed as part of the Argyll and Clyde
Health Board and was in the process of being integrated into NHS Greater Glasgow
and Clyde. Changes were being introduced over that period including changes to
the infection control and antibiotic policies. The majority of the cases occurred
during the peak winter admission period from December 2007 through to April 2008
when antibiotic usage for the treatment of respiratory tract infections would have
been high.
The organisation of infection control within NHS Greater Glasgow and Clyde
appeared to have been complex and in the process of changeover and
amalgamation at that time with Infection Control Working and Support Groups, Acute
and Board Committees. The IRT concluded from interviews and review of
documentation that there was a lack of clarity and leadership in several key roles
and responsibilities, Committee structures and lines of reporting.
Uncertainties over the longer term future of the hospital had led to lack of investment
in the upgrading and maintenance of the hospital. Critically the capacity of the
hospital to effectively isolate CDAD patients was limited due to lack of suitable
facilities for effective infection control practices such as appropriate bed spacing,
single rooms and hand wash basins. A further factor was the frequent transfer of
patients within Vale of Level Hospital and between other hospitals, particularly Royal
Alexandra Hospital in Paisley. The IRT also found evidence of overcrowding of beds
within bays at that time and it was reported by patients and relatives that despite
wards being closed, pressures on beds meant that additional cases had to be
accommodated within closed bays/wards. The IRT identified that there was a need
to strengthen clinical leadership and accountability within the Vale of Leven Hospital
and across all professional structures.
13
b) Review the adequacy of the surveillance systems at the hospital during this period
An alert condition system was in operation for patients with diarrhoea. The IRT was
satisfied that ward staff took appropriate steps to take samples for laboratory testing
from patients with unexplained diarrhoea and to try and isolate symptomatic patients
as best they could given the limited facilities. Stool samples were tested and
reported promptly by the laboratory and results were passed immediately to the ward
at weekends and the Infection Control Nurse during the week. Reporting of results
by Consultant Microbiology staff was done on a rotational basis from an off-site
laboratory, there have been long-standing difficulties recruiting to the post on-site at
the Vale of Leven Hospital. The Infection Control Nurse responded to these alerts
appropriately on an individual case by case basis with ward liaison visits. The
Infection Control Nurse also attended the daily bed management meetings.
The local surveillance at the time used a coloured card system to flag positive cases
and was managed by the Infection Control staff based on reporting of positive
samples from the laboratory. A critical issue in such surveillance is identification
when the number of cases breaches an agreed control level in any one ward in a
defined period of time, usually per month. This is a complex estimation and relates
to the ward size and the expected numbers of cases. At the time of the peak of new
cases in January to April 2008 there were no agreed levels to alert local staff of an
excess number of new cases over a period. The pattern of cases at the time
appeared sporadic rather than clustered and analysis was made more difficult by
frequent transfers of patients between wards. During April 2008 a computerised
Statistical Process Control Chart (SPCC) was introduced for the purposes of
surveillance at a ward and hospital level. The IRT concluded that although the ward
and laboratory systems at the time were adequate in identifying and managing
individual cases, local systems did not allow the detection of the increased numbers
of cases over the period, which in retrospect on examination of the SPCC showed a
significant increase.
14
The national mandatory C.difficile reporting system run by Health Protection
Scotland receives and analyses data at a Health Board level and reports on a
quarterly basis for the purposes of national surveillance of CDAD in those over 65
years of age to assess the impact of national strategies. The laboratory was
compliant in reporting the required cases to Health Protection Scotland.
C) Review the adequacy of the infection control procedures at the hospital during this period
There are several components to effective prevention and control of C. difficile and
other infections including prudent antibiotic prescribing and management, rapid
detection and surveillance of cases allowing early intervention to reduce the risk of
spread between patients, early and effective isolation of symptomatic patients,
adherence to standard and transmission based infection control precautions such as
the thorough cleaning of the environment and equipment, hand washing and use of
Personal Protective Equipment (PPE) such as gloves and aprons. Staff must have
knowledge of these components and be competent and diligent in their application.
These systems should be checked by an audit programme.
A major limitation was the lack of appropriate facilities at the Vale of Leven Hospital
for isolation and when several affected patients were in the Hospital at one time, the
practice of managing affected patients together in one area (cohorting) was
employed. Infection control measures including handwashing and wearing of
protective clothing were reported to be inconsistently deployed throughout the Vale
of Leven Hospital by the families.
The audits of cleaning that were undertaken during the period including Peer/Public
inspections indicated that the Vale of Leven Hospital maintained acceptable
standards in cleaning, although it is noted that during the monthly cleaning services
monitoring review carried out in January 2008, one ward was scored as red (68%)
mainly for dust accumulation throughout the ward. Re-audit in the following month
showed an improvement, though some surfaces were still recorded as being dusty or
dirty. Records of the 2008 environmental audit cycle carried out by the Infection
Control Nurses appeared to have started in April 2008. In 2007 audit scores for the
15
environment varied from 65 – 90%, handling and disposing of linen seemed to vary,
hand hygiene compliance 71 -87%, use of PPE 93 -100% and isolation precautions
87-100%. The IRT was unable to assess what remedial actions and re-audits were
done in response to any low score. Patients and relatives reported that Infection
Control Policies were inconsistently applied with regard to patient isolation, infection
control practices and communications with patients and their families. Systems and
processes would have benefited from stronger clinical leadership and arrangements
for regular clinical supervision and support.
In terms of antibiotic prescribing, The North Glasgow Prescribing Guidance book
was reported to have been issued to all doctors at induction and changeover and
circulated to Consultants. Laminated posters were put up in the Hospital in Nov/Dec
2007. The pharmacists did attend the Hospital Infection Control Group but reported
that the last meeting was in September 2007. Antibiotic advice was readily available
from Consultant Microbiologists based at Clyde for both Clinical and Pharmacy staff.
There was however, no evidence provided of any audits of prescribing or feedback
to staff on antibiotic usages during the period though subsequently this was seen by
the IRT.
d) Review the adequacy of current surveillance and the infection control arrangements
A new surveillance system using Statistical Process Control Charts was introduced
in April 2008 and is in the process of implementation. It will require time and close
monitoring to ensure that the new system provides the required level of detail at both
ward and hospital level. To be effective these will have to be produced in a timely
manner and understood by staff. A system of linking deaths registered with the
Registrar General Office has now been established. A new infection control
structure has been introduced across NHS Greater Glasgow and Clyde from the 1
July 2008. This new structure will take time to become established with new
organisational arrangements and line management responsibilities and due
cognisance of the need for good communication and team development
requirements should be taken into account during this period of yet more change.
The new structure still has complexities such as the microbiology laboratory being
16
organised in different sectors from Infection Control Doctors and Infection Control
Teams and no local linkage with Community Infection Control other than at Board
level. A hand hygiene co-ordinator has been assigned duties to cover the Vale of
Leven Hospital and it was made clear to the IRT that disciplinary action will be taken
against any member of staff who does not fulfil their duties in respect of hand
hygiene compliance in particular.
Following the appointment of a new Microbiologist at the beginning of 2008 with a
designated role as Infection Control Doctor for the Vale of Leven Hospital, the IRT
saw documentation that provides evidence that this individual will provide much
needed leadership and support to the Infection Control Team, clinical and non-
clinical staff at the Hospital.
NHS Greater Glasgow and Clyde is in the process of appointing an Antimicrobial
Pharmacist to Clyde. The IRT was shown data on antibiotic usage that will in the
future be prepared for the Vale of Leven Hospital to support good prescribing habits
and provide feedback to clinical staff. A process to assess the implementation of the
policy through monitoring the use of antibiotics is being set up by nominated
Pharmacists. This is just starting and needs to be vigorously implemented and
supported at the highest level through continued training and monitoring. The
Antimicrobial Management Team gave a presentation to clinical staff on 17 June
2008 to promote the empiric antibiotic usage guidance with restrictions on groups of
antibiotics thought to be associated with an increased risk of CDAD. These agents
have been removed from stock and are only available for prescription after
discussion with a Consultant Microbiologist.
NHS Greater Glasgow and Clyde has undertaken its own internal review and as a
consequence several actions have been identified to improve structures and
processes.
17
e) Review the adequacy of relevant facilities to prevent and contain C.difficile at the hospital, such as the availability of hand hygiene facilities
Immediate work has begun to improve the environment in several wards. This will
take at least 20 weeks to complete and will include repair/decorative works and the
installation of additional hand wash basins. The clinical areas will still lack adequate
storage space, isolation facilities and confidential areas for relatives to meet with
staff. Work has started to re-instate the Lomond ward to allow greater room between
beds in other areas.
Ward charge nurses have a crucial role in ensuring the delivery and maintenance of
clinical standards. The IRT and families recognised a commitment from this group to
caring and hardwork. It was identified however that there is a need to further
empower and strengthen this role and to provide the necessary clinical support for
further development and a strengthened professional leadership structure to Board
level.
f) What notifications were given by the Vale of Leven Hospital to the Greater Glasgow and Clyde Health Board infection control committee and Health Protection Scotland
An excess number of cases at Vale of Leven Hospital were identified by an Infection
Control Doctor investigating a number of 027 ribotype of C.difficile at the Vale of
Leven Hospital and Royal Alexandra Hospital. This was reviewed by the Clyde
Infection Control Team on the 14 May 2008 and reported to the Health Board
Infection Control Committee. An incident control meeting was held on 21 May 2008
following which both Health Protection Scotland and the Scottish Government were
informed and the Cabinet Secretary was briefed by officials. A media statement was
prepared by NHS Greater Glasgow and Clyde and disseminated on 22 May 2008, at
that time the incident team were only aware of one death. A review of the cases
following press enquiries in early June 2008 about the number of deaths associated
with C.difficile infection at the Vale of Leven Hospital identified there were 16 deaths
attributable either directly or contributory to C.difficile infection. A formal Outbreak
Control Team meeting was convened by NHS Greater Glasgow and Clyde on 10
18
June 2008 involving Health Protection Scotland and the Scottish Government were
updated following this meeting.
g) What procedures were followed for informing the Scottish Government of what action has been taken or could be taken,
The procedures were based on those recommended by the Watt Group Report
(2002) outbreak/episode risk matrix. The Scottish Government was informed at the
time the cluster of 027 ribotype cases was identified and when the Outbreak Control
Team was convened. The information included the details of the investigation and
the actions that had been taken immediately by both the incident team on 21 May
2008 and the Outbreak Control Team on 10 June 2008.
h) Make recommendations about the procedures and systems that should be adopted at the hospital so that good infection prevention and control procedures are in place As a matter of urgency the Independent Review Team recommends:
i. That current infection control policies and procedures are reviewed to ensure that current best practice guidelines with respect to the prevention and control of C.difficile infection are implemented and monitored including relevant training and education for all staff. This should include C.difficile care Bundles to support audit, the C.difficile checklist and the Template for Local Surveillance produced by Health Protection Scotland. (Additional guidance from Health Protection Scotland is expected in the Autumn 2008)
ii. That current best practice guidelines for prudent antimicrobial
prescribing are implemented and monitored both in the Acute and Community sectors and that the Hospital works towards compliance with the Scottish Management of Antimicrobial Resistance Action Plan (2008)
19
iii. That infection control roles, responsibilities, processes and committees must be aligned to clearly establish lines of professional and clinical responsibility, accountability and support clinical leadership across all levels including the Community.
iv. That a development plan to strengthen, support and empower the role of
the Charge Nurse is put in place and to improve the professional leadership structure to Board level.
v. That the process for communication with patients over infection control
issues be improved in consultation with patient representatives.
vi. That the Board ensures a safe environment for patient care, develops a pre-planned maintenance programme for the Vale of Leven Hospital, and reviews current isolation facilities, using a risk management process.
vii. That the Board adopts a consistent approach through best practice and
training in relation to death certification for Healthcare Associated Infection.
viii. That an external and independent audit of the implementation of these
recommendations should be conducted by the end of 2008 and that patient representatives should be included as part of the review team.
20
Annex A List of those interviewed by the Independent Review Team
Dr Syed Ahmed
Dr Tom Walsh
Ms Joan Higgins
Dr Lynda Bagrade
Ms Annette Rankin
Mr Jon Menzies
Dr Andrew Seaton
Ms Ysobel Gourley
Ms Helen O’Neill
Ms Carole Reed
Ms Gillian Mills
Ms Catriona Sweeny
Mr Alex McIntyre
Dr Robin Reid
Ms Isobel Ferguson
Ms Elizabeth Rawle
Ms Marie Martin
Mr Jim Crombie
Ms Mary Morgan
Ms Sue Wilson
Dr Debbie Mack
Ms Liz Hunter
Ms Susan Craig
Ms Lesley Fox
Ms Ann Madden
Ms Laura Shepherd
Ms Jean O’Brien
Ms Sandra McNamee
Mr Tom Divers
Ms Rosslyn Crocket
21
Dr Anne Eastaway
Dr Elizabeth Biggs
Professor John Coia
Dr Craig Williams
We also spoke with 22 patients and relatives who had been affected by the outbreak.
Independent Review of
Clostridium difficile Associated Diseaseat the
Vale of Leven Hospitalfrom December 2007 to June 2008
w w w . s c o t l a n d . g o v . u k
© Crown copyright 2008
This document is also available on the Scottish Government website:www.scotland.gov.uk
RR Donnelley B57209 8/08
Further copies are available fromBlackwell’s Bookshop53 South BridgeEdinburghEH1 1YS
Telephone orders and enquiries0131 622 8283 or 0131 622 8258
Fax orders0131 557 8149
Email [email protected]
