CONDITIONS at a hospital where 18 patients died after contracting the Clostridium difficile bug were yesterday described as "disturbing" and "appalling" by Scotland's health secretary.
An independent review strongly criticised facilities at the Vale of Leven Hospital in Dunbartonshire, where 55 patients were diagnosed with C difficile between December and June.
A shortage of hand basins, a lack of isolation facilities, beds cram
med close together and "shabby" surroundings were all condemned in the review.
Another report also published yesterday, which studied cases of the infection across Scotland, found that during the same six-month period of the Vale of Leven outbreak, 285 deaths were linked to C difficile across the country.
Health chiefs at the Vale of Leven now face tough questions about the circumstances which led to the deaths of 18 vulnerable patients in their care – nine where C difficile was the main cause and nine where it was a contributory factor.
The dead included Ellen Gildea, Margaret Gaughan, Alister Johnston and Sarah McGinty.
In response to calls by relatives for a full public inquiry into the outbreak, Nicola Sturgeon, the health secretary, said she had referred the report to the Lord Advocate, who had asked the area procurator-fiscal to consider whether further action should be taken.
The procurator-fiscal would have the power to call for a fatal accident inquiry into the deaths and could also consider whether there was a case for criminal proceedings.
Yesterday, the families of the deceased renewed their demand for a public inquiry into the outbreak as the best way of resolving what went wrong.
Ms Sturgeon said the report of the independent review team, led by Professor Cairns Smith from Aberdeen University, made for "disturbing reading".
The report criticised the surveillance systems in place to flag up increases in cases of C difficile in the hospital.
The health secretary said excess cases were found in January, February and May this year.
"These peaks should have triggered action but there was not an effective local surveillance system in place," she said.
A separate report by Health Protection Scotland (HPS) found that deaths linked to C difficile were significantly higher at Vale of Leven than the national average during the period studied.
The reasons for this high rate include the fact that many of the cases involved a strain of the disease called 027, which causes more serious illness.
The state of the hospital facilities and infection control procedures, as well as other health problems suffered by patients at the hospital, were also linked to the high mortality rate.
Ms Sturgeon said: "With regard to the state of facilities and procedures at the Vale of Leven, the picture painted by the review team report is appalling and completely unacceptable.
"As the report makes clear, it is a picture of a hospital suffering the consequences of ten years of uncertainty about its future.
"It identified a lack of clear focus and leadership in relation to infection control, a poor standard of physical fabric in the hospital, with inadequate hand hygiene and patient isolation facilities, beds placed too close together and a shabby appearance, even where cleaning was of a high standard.
"This was compounded by poor staff morale and deficiencies in knowledge and training around infection control in general, and C difficile in particular," she said.
Ms Sturgeon said the absence of clear lines of professional responsibility had "fostered an environment where there was inadequate management of clusters of cases at ward level, or awareness of problems at higher levels".
There was also a lack of knowledge among staff about infection control measures.
Ms Sturgeon acknowledged the extent to which questions over the hospital's future, including the withdrawal of several services, had led to neglect.
She said: "I can't answer for what happened in the period before I took office, but I am determined now, as I have been over the last year, to ensure that (the] hospital does not continue to suffer death by a thousand cuts."
Yesterday's report by HPS, which studied cases across Scotland, found there were a total of 3,174 cases of C difficile reported between December last year and June this year.
There were also 86 deaths where the infection was mentioned as being the underlying cause, and a further 199 where it was a contributory factor – amounting to a 9 per cent fatality rate.
Rates of C difficile were also found to be higher than expected at Aberdeen Royal Infirmary. However, unlike Vale of Leven, staff were aware of the increase, which was linked to a large outbreak of the norovirus.
Increases were also identified by staff at Victoria Hospital in Kirkcaldy and Wishaw General Hospital in North Lanarkshire.
One hospital, Woodend Hospital run by NHS Grampian, had a higher level of deaths linked to C difficile.
Ms Sturgeon, whose grandmother battled C difficile in the last days of her life, said while the statistics were reassuring in terms of rates across Scotland, the number of deaths linked to C difficile was still not acceptable.
And she announced moves to improve surveillance and introduce a "zero tolerance" policy on poor hand hygiene, alongside other infection control measures.
Tom Divers, the chief executive of NHS Greater Glasgow and Clyde, apologised to patients and families affected by the C difficile outbreak at Vale of Leven.
He said he recognised the concerns of relatives that they were not kept properly informed, adding that he had ordered immediate improvements, including improved hand-washing facilities and better bed spacing.
Yesterday, the families of the dead welcomed the report, but maintained their call for a full public inquiry.
Michelle Stewart, whose mother-in-law died in the outbreak, said: "We are pleased we have got an apology from the health secretary and the health board. But only a full public inquiry will answer all the questions that we have."
Ross Finnie, health spokesman for the Scottish Liberal Democrats, said the Vale of Leven report was "damning in its conclusions".
Patrick Maguire, the solicitor representing families affected by the Vale of Leven outbreak, said:
"The families' main concern is for a public inquiry to be held into this outbreak."
Hugh Pennington - Scotland is still playing catch-up with C difficileTHESE reports raise several issues of concern regarding Clostridium difficile in Scotland's hospitals.
There are a number of proposals made as a result of what was found to have gone wrong at Vale of Leven, such as improved hand hygiene measures and better surveillance.
But I am slightly pessimistic as to whether these measures on their own will be sufficient to tackle the problems with C difficile we are now facing.
A zero-tolerance approach to non-compliance with hand-hygiene is admirable, but achieving 100 per cent compliance is difficult as there will always be situations where staff are too busy.
In the case of Vale of Leven, there were simply not enough wash basins in the right places and this is clearly something that needs to be addressed with urgency, as does the provision of single en-suite rooms.
Improving surveillance of C difficile is also essential. The systems currently in place failed to pick up what was happening at the Vale of Leven until it was too late. Tracking the spread of infection using state-of-the-art fingerprinting methods is a must. The reports do not mention it.
Even if a higher number of cases had been identified, there is no system that links those cases to the outcome, such as if it results in a death.
Having such a system could help alert hospitals to problems at an earlier stage so they can take action to stop further patients falling ill.
There is a big issue in Scotland in that we are behind England in terms of getting to grips with C difficile. They started their mandatory national surveillance system two years before we did and we are now playing catch-up.
The problem with the independent review by Cairns Smith is that it was put together in a very short space of time and could not go into great detail of what happened at Vale of Leven.
In principle I would support a full public inquiry.
The remit of such an inquiry could be widened to tackle issues such as death certification, so we can get a better idea of deaths linked to many infections, not just C difficile.
It could also make recommendations on the clear action Scotland needs to take to tackle hospital acquired infections.
At the moment we are simply following England in tackling these problems and we clearly need to be focussing more attention on reducing the death toll from these infections in any way we can.
Countries like Holland and Norway are streets ahead of us.
• Hugh Pennington is Scotland's leading microbiologist.
'Cramped, stuffy and shabby' say visitorsVISITORS to the Vale of Leven Hospital during the outbreak of Clostridium difficile described a place lacking in investment, with shabby surroundings and a stuffy environment.
The Dunbartonshire hospital, built in the 1950s, is typical of many from this time, with a series of wards with smaller bays caring for several patients in close proximity.
Like other NHS facilities, the hospital has seen services cut, as some aspects of care have been centralised elsewhere. The maternity unit closed in 2002, shortly followed by A&E. The report noted that the hospital had been under threat of closure for more than ten years and said uncertainty about its future led to a lack of investment.
Michelle Stewart, whose mother-in-law, Sarah McGinty, died with C difficile in February, said the bays where the patients stayed were stuffy and cramped. "There was not much room to move in the wards. When my mother-in-law was sat in her wheelchair next to the bed, nobody could get to the sink to use that."
Another visitor to the hospital, who asked not to be named, said:
"There were boxes of gloves and aprons right next to patients. Sometimes visitors would sit on the boxes because there was not enough chairs on the ward.
"There was also a laundry storage unit nearby where they were constantly collecting clean laundry. It was always left open with people passing back and forth. In the bay my mother was on before she died there was no sink."
AT A GLANCE• Fifty-five patients at the Vale of Leven Hospital developed Clostridium difficile in the six months December 2007 to June 2008. 18 deaths were linked to the infection. Uncertainties about the longer term future of the hospital led to lack of investment in the upgrading and maintenance at Vale of Leven.
• Facilities were "inadequate for effective patient isolation and infection control" and there were frequent patient transfers between wards and other hospitals, increasing the risk of infections spreading.
• The death rate linked to C difficile as recorded on death certificates was higher than expected during the six-month period studied.
• There was no system at the hospital for analysing rates of new cases of C difficile to identify if these exceeded expected limits.
• There was a lack of leadership and supervision, clarity of roles and responsibilities at the hospital.
• Facilities were inadequate in terms of hand washing, accommodation with toilets, appropriate spacing between beds, clinical and storage space.
Health service chiefs who must come up with answersSENIOR health bosses in NHS Greater Glasgow and Clyde must take action on the failings which led to the outbreak of C difficile at the Vale of Leven hospital.
Tom Divers, chief executive of the health board, has apologised to the families of those affected by the outbreak at the hospital.
On a salary of £139,000, he is the one with responsibility for ensuring the restoration of public confidence in NHS services in the area.
Another key figure is the board's chairman, Andrew Robertson, who earns a part-time salary of £38,532.
But there will also be tough questions for senior facilities and clinical managers over failures at all levels.
Dr Syed Ahmed, NHS Greater Glasgow and Clyde's consultant in public health medicine, chaired the C difficile outbreak control team at the Vale of Leven hospital after the cases were discovered.
He admitted that, from an infection control point of view, it was "clear more could have been done to identify the risks earlier and potentially reduce the spread of infections".
And he said improvements in infection surveillance and control measures might have cut the incidence of C difficile infections.
Yesterday, when asked if she was looking for resignations as a result of the Vale of Leven outbreak, Nicola Sturgeon, the health secretary, said she was more concerned about learning lessons.
She said there was a history of neglect going back many years at the hospital. "I am much more interested in getting this right than trying to have an exercise of apportioning individual blame," she said.
