Nobody knew whose job it was to ensure taps, baths and shower heads were flushed at least once a day.
The failures were “either total incompetence or dereliction of duty”, according to Professor Hugh Pennington, emeritus professor of bacteriology at the University of Aberdeen.
He said: “Health professionals have known for many years that these very basic practices can and do prevent infection.
“If these very basic steps had been taken, some of the deaths and infections we’ve seen at this hospital could have been prevented.”
Patients including ten-year-old Milly Main have died because of dirty air and water at the hospital.
Inspectors from Health Improvement Scotland made a spot visit to the hospital. Their report found that the health board had not kept proper records vital to prevent water-borne infections in high-risk wards.
Despite instructions from Scotland’s former Chief Medical Officer dating back to 2013 that all hospital taps must be flushed for at least a minute once a day and detailed records kept, documents show NHS Greater & Clyde failed to do so.
Inspectors found staff were unclear who was responsible for carrying out the flushing routines and records were inconsistent.
The inspectors warned: “At least one section of the audit scored 33 per cent.
“We were concerned assurances would be taken from the overall high score without recognising the low scores within the separate sections.”
They also raised concern that, when senior charge nurses were not available, the senior nurses on duty could not access audit results and action plans.
A nurse was found carrying body fluids to the sluice room without wearing protective clothing to prevent infection.
Despite warnings in 2018 not to use bladeless fans because of infection issues, they were still being used.
Lockable bins were left unlocked and accessible to the public. Staff were handing out food but not complying with hand-washing infection control precautions. Medical staff were preparing intravenous infusions within splash contamination areas of a sink.
Professor Pennington said: “It’s clear that, with the level of deaths and infections and evidence that even basic measures were not being implemented, things were very wrong.”