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Lessons Learned from Vale Outbreak

November 24, 2014 4:51 PM

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THE Chairman and Chief Executive of NHS Greater Glasgow and Clyde have today apologised to the patients affected and to the families of those who died in the Vale of Leven outbreak of 2008.

Following today’s publication of the Vale of Leven Inquiry, Andrew Robertson, Chairman, said: “On behalf of the Board and our staff, I would like to offer a full and unreserved apology to the patients affected and to the families who lost a relative to C-diff in the months between January 2007 and late 2008.

“This was a terrible failure and we profoundly regret it.

“I can give the firmest of assurances that, as a result of the lessons that have been learned, this could not happen again.

“We take the control of infection extremely seriously. This is very visible at ward level, at Board level and at all stages in between. It is evident when you go round the wards and see the surveillance charts on the walls and it is evident at the regular Board meetings when the details of hospital acquired infections are shared with the Board and with the public. As a result, C-diff levels at the Vale of Leven Hospital have dropped by 80% since 2008. That is unequalled in Scotland.

“We note that Lord MacLean acknowledges in his report that NHSGGC reacted swiftly and effectively to the emergence of the C-Diff problem at the Vale and that the steps that were taken to improve prudent prescribing have had a dramatic impact on the number of C-diff cases.

“We also note the criticisms of individual members of staff. What I can say today is that we will consider Lord MacLean’s report in detail and what our next steps may be. It would be absolutely wrong at this stage to discuss the individuals concerned.”

Chief executive, Robert Calderwood, said: “Re-iterating my personal apology I hope the relatives can take some comfort that the lessons learned from this outbreak have resulted in significant improvements in clinical practice, for instance, in more prudent prescribing of antibiotics. These changes have led to dramatic reductions in C-Diff infection rates not only at the Vale, but throughout the whole of NHS Greater Glasgow and Clyde and indeed across Scotland.

“In addition, we’ve invested £14 million in the Vale to deliver a wide range of improvements including better bed spacing and improved hand washing which have contributed to a further reduction in the instances of healthcare acquired C-Diff infection.

“We note that the Inquiry recognises that the Board responded promptly to the discovery of failures that had occurred in the Vale prior to June 2008.These major improvements introduced since the tragic events of six years ago have made the Vale and all of our hospitals in Greater Glasgow and Clyde safer for patients than they have ever been.”

Dr Jennifer Armstrong, Medical Director, said: “There are three crucial areas where we have taken action – prevention, treatment and monitoring.

“C-diff is a germ that is present in 10-15% of adults and around 20% of people coming into hospital. It is normally kept in check by the good bacteria present in your gut. In 2008, it was common practice to prescribe powerful broad-spectrum antibiotics which would kill all of the germs in the gut, including the ‘friendly bacteria’ that would normally keep the C-Diff infection at bay.

“In response to the events of 2008, we changed the culture of antibiotic prescribing by GPs and hospital doctors and we now mainly use antibiotics which target specific germs and do less harm to the friendly bacteria. However there are occasions when doctors need to prescribe the more powerful antibiotics to control really serious infections. However, antibiotic use is now strictly monitored by a specialist team of doctors and pharmacists.

“While cross infection with C difficile is now extremely rare, unfortunately some patients will develop C difficile as a result of essential antibiotic treatment either in the community or in hospital. Our clear priority in this situation is to prevent the spread of the infection to other patients in our wards. We ensure that all patients with diarrhoea are immediately isolated and infection control precautions put in place. When the diagnosis of C-Diff is confirmed by the laboratory we have created an automatic alert for specialist infection control staff to link with nurses and doctors on the ward to verify that all treatment and precautions are being taken as well as ensuring that the patient is kept updated on their illness.

“Finally to ensure that all infections are detected and all precautions taken we have significantly strengthened our system of monitoring and surveillance. I must emphasise, that this is always work in progress and we are focussed on detecting any areas where we can improve and rapidly putting in place better ways of caring for patients.”

Rosslyn Crocket, Nurse Director, said: “We have learned a huge amount about how to better control infection rates since 2008. Our nurses have been trained in the very latest techniques, and our nursing leaders have been given additional training and support to allow them more time to ensure that the care given to patients is of the highest possible standards and that care is well documented.

“We have also implemented a system called “Active Care” which delivers clinical care in prescribed intervals of time and crucially allows staff to keep a record of exactly when colleagues have checked on patients and when they have been asked particular questions.

“With more than one nurse caring for the same patient the introduction of Active Care allows each nurse or AHP to view a record of care which provides assurance that the patient has had their care reviewed by a nurse within the documented time interval.”


For further information either telephone 0141 201 4429 or email [email protected].  

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