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NHSGGC responds to the Oversight Board Report and Case Note Review

Monday, March 22, 2021

The reports published today cover an extremely challenging situation as we investigated and responded to unusual infections in young patients and the possibility that these infections were linked to the environment.

The reports highlight a number of significant issues for the Board.  We fully accept that there is important learning for NHSGGC and are committed to continuing to address the issues within the reports.

This has been an incredibly difficult period for patients, families and staff and we are very sorry for the distress caused.   For those whose infection episodes were judged by the Case Note Review panel to be possibly or probably linked to the hospital environment, we apologise unreservedly.  

The question over potential links between the hospital environment and infections amongst young patients treated in RHC haemato-oncology unit has persisted for a number of years. As the two reports published today have highlighted, this has been a very difficult question to answer.

Whilst it has not been possible to provide conclusive answers to these questions, significant action has been taken to mitigate the risk of infection from the environment.  As soon as we recognised the potential risks with the water supply in 2018, we took action. This included point of use filters for water outlets, chlorination treatment of the water supply, and ultimately the relocation of Wards 2A and B to another part of the hospital. 

In total, £6million was spent on addressing water supply issues.  In addition, a further £8million has been invested in Wards 2A and B, including a significant upgrade of the ventilation system. This will deliver the one of the safest clinical environments within the UK and with the improvements that have already been made and continue to be made, infection rates at the hospital remain low. 

Over the past year we have also worked closely with the Oversight Board and with Professor Angela Wallace, appointed by the Scottish Government as Interim Director of Infection Prevention and Control.

We have reviewed and strengthened our infection control and protection arrangements including the development of stronger relationships between the Infection Prevention and Control team and microbiologists. We have also worked to build and develop the Board’s communications and engagement with patients and families. 

We are encouraged to note that the work to date has been endorsed by the Oversight Board.

There is undoubtedly further important learning for NHSGGC and for Scotland as a whole, from the unprecedented circumstances that we faced.  We are fully committed to continuing to improve and to implementing the recommendations from these reviews. 

Jane Grant, Chief Executive of NHS Greater Glasgow and Clyde, said: “This has been a very challenging time for patients, families and staff and I am truly sorry for this. For families, children and young people, undergoing cancer treatment is already an incredibly difficult situation and I very much regret the additional distress caused.

“Whilst we have taken robust and focused action to respond to issues, and at all times have made the best judgements we could, we accept that there are times when we should have done things differently. 

“I would like to thank our staff who have worked so hard in difficult circumstances to deliver quality care, putting our young patients and their family at the centre of everything they do.

With the improvements that have already been made and that continue to be made, infection rates at the hospital remain low.  Patients and families can have confidence in the care they receive and in the environment within which they receive it.”

Speaking on behalf of her clinical colleagues, Professor Brenda Gibson, Lead Clinician, Haemato-Oncology, said: “Throughout this exceptionally difficult period, our clinical team has been, and remains, entirely focused on caring for and supporting our young patients and their families.

“Person-centred cancer care involves a partnership between staff and families and we are committed to maintaining and developing strong relationships with parents and carers as we move forward.”

Professor John Brown CBE, Chairman, added: “On behalf of the Board, I offer my sincere apologies to all the children and families who have been affected by these issues.  The Board continues to take this situation very seriously, and has welcomed external support and advice as we have worked to understand, and respond to, an unprecedented set of circumstances not previously faced in the NHS. 

“These reports provide further opportunity for improvement and learning for NHSGGC and we are fully committed to that course of action.”



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Last Updated: 22 March 2021