Two reports have been published following an independent case note review into infections in children and young people being treated for blood disease or cancer at the Royal Hospital for Children in Glasgow, part of the QEUH campus.
The review, the results of which were leaked on Friday, found that a third of the 118 infections considered were “most likely” to have been linked to the hospital environment, and that the deaths of two of the 22 children who died were at least partly due to their infection.
It examined the number of children who were affected by a type of infection caused by Gram-negative environmental (GNE) bacteria between 2015 and 2019, and whether those infections were linked to the hospital.
An infection linked to the hospital was the “primary cause of death” of one young cancer patient, while infections from contaminated water at the hospital were an “important contributory factor" to the death of another child, the report found.
The infections resulted in longer hospital stays for patients and the need for additional treatment, as well as delays in planned treatment in some cases.
An Oversight Board report into infection prevention and control practices at the hospital has also been published.
The board acknowledged that NHS Greater Glasgow and Clyde had taken action to address issues with water contamination, but found that the health board’s response was too short-term and reactive, and that there were failings in governance.
Health secretary Jeane Freeman said: “These findings, which will inform the ongoing Public Inquiry, do not fault the quality of care provided by frontline NHS GGC staff, but they do highlight serious failings at the Health Board level. I agree with the Oversight Board’s conclusion that NHS GGC should remain at Stage 4.
“Efforts have been made to improve and adopt the culture of transparency, openness and clinical leadership I expect. However, we will continue to work closely with the Board to ensure these are demonstrably embedded – to provide the assurance patients and their families deserve, and also so that these lessons can be considered more widely across NHS Scotland.
NHS Greater Glasgow and Clyde said the reports covered an “extremely challenging situation” and highlighted “a number of significant issues” for the health board.
Jane Grant, chief executive of NHS GGC, 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.
Scottish Labour leader Anas Sarwar urged the Scottish Government to deliver a fatal accident inquiry to the families of the children affected.
He added: “The failings uncovered are directly linked to the hospital environment and they would never have come to light if it wasn’t for the bravery of NHS whistleblowers who spoke out despite repeat attempts to silence them by the management.”