Insight: What’s gone wrong at the Queen Elizabeth University Hospital in Glasgow?

Kevan Christie asks how a centre of NHS excellence became the focus of a Crown Office investigation into the death of a 10-year-old linked to pigeon droppings

The Queen Elizabeth University Hospital in Glasgow opened to great fanfare in April 2015 with a royal visit – from the very monarch after whom it was named.

Immediately tagged a “super-hospital”, it was the Starship Enterprise of a shiny, bright new future for the NHS in Scotland. The latest Scottish Government flagship – an £842 million monument to efficiency – was one of the biggest medical campuses in Europe, promising a massive shake-up to health services in the city.

The locals were quick to dub it the “Death Star” due to its shape, size and the landing pad for aircraft on the roof. But the sheer scale was inevitable as it would be serving 41 per cent of Scotland’s population.

A BBC programme followed – Scotland’s Superhospital, a two-part documentary that followed staff and patients at the four hospitals the Queen Elizabeth would replace – Southern General, Victoria Infirmary, Western Infirmary and Yorkhill Children’s Hospital – as they prepared to move into their new home. A second series aired in 2017 showing NHS staff coping heroically with the life and death crises they have to deal with on a daily basis.

However, it had only taken a month for cracks to appear in the successful image of the new hospital, and stories began to emerge that it might not be the state-of-the-art facility the Scottish Government had promised.

From reports of it resembling a “war zone” during bank holiday weekends, to the ongoing waiting times saga and a raw sewage leak leading to operations being cancelled, comparisons to battlefield triage did not seem that far fetched.

Scottish Labour health spokeswoman Monica Lennon has drawn attention to a “laundry list of problems”. They include cladding being removed in December 2017 due to similarities with material used in the doomed Grenfell Tower, and a glass panel crashing ten floors from the hospital in August 2018.

Last month there were reports of bacteria in the water supply at the cancer ward in the children’s hospital on the campus.

And on Friday prosecutors from the Crown Office confirmed they were investigating the death of a ten-year-old boy after he contracted Cryptococcus infection linked to pigeon droppings at the hospital at the end of last year.

Another patient diagnosed with the condition died there but their demise was not caused by the infection.

The tragedy has led Health Secretary Jeane Freeman to start an inquiry into the design, construction, handover and maintenance of the hospital amid concerns its quality is “less than satisfactory”.

The source of the infections is also being probed amid reports of a third person left fighting for their life after contracting a second fungal infection, Mucor, and a fourth who had the same condition but was not requiring treatment.

It was not supposed to be like this at a facility that should have been the pride of the health service. But then some of the issues encountered may be a direct result of the project’s ambition and size.

Architect Malcolm Fraser, who is behind award-winning modern buildings including Dancebase in Edinburgh and Scottish Ballet in Glasgow, said the 14-floor “monster hospital” is not a “happy building” and that bigger places tend to “cut corners”.

He said that “mechanical ventilation ducts are perfect places for cooking up virulent nasties”, adding that hospitals tended to be built with mechanical ventilation though it was possible to design them with natural ventilation.

Fraser said the inquiry should start with how the hospital was built and the processes in place.

“If the building’s not built perfectly we have these places where disease can come in and problems can happen,” he said. “At some point we’re going to have to understand that making buildings machines is not conducive to health and recovery.”

Robert Menzies, who spent 40 years designing hospitals, said he believed that small specks of dust from pigeon droppings must have got into the hospital’s air-conditioning system, through fans, vents and filters.

But he added that infections from fungi in bird droppings were rare and described the events at QEUH as “unexplained and puzzling” as the facade of the hospital is flush, with no perches, and its roof is flat.

Freeman has suggested that there was a hole in a plant room on the building’s 12th floor – that might have been a way in for bugs.

Menzies believes investigations will begin in that plant room and then follow through the air conditioning.

“There is either a flaw in the design or a flaw in maintenance,” he said. “There is guidance on where hospitals should install high-efficiency particulate air filters – HEPA filters for short. These multi-layer fibreglass webs should catch bugs. But no system is perfect, human or machine.”

Former health secretary Alex Neil warned that there might be more at stake than just “teething problems” at QEUH, as the hospital has been up and running for four years and such issues should have been identified and dealt with long before now.

Welcoming the Health Secretary’s decision to launch an investigation, Neil said: “It might be more basic than a teething problem – it might be a design fault or something more systemic and that’s the purpose of this review to find that out.

“Were these a series of problems that were unforeseeable and not part of a design problem – for example the water supply? I’m not qualified to say. There are a number of problems – obviously the problems arising from this infection from pigeon poo.

“The children’s cancer ward is closed for a year and the children are scattered through the adult wards while that’s happening, and again that’s because of design problems in the hospital.

“Therefore I think the serious problems that have arisen are mainly around the design of the building.”

Speaking to Scotland on Sunday Neil echoed the concerns he made last week around a “major failure of governance” at NHS Greater Glasgow and Clyde.

He said that the QEUH board needed to be “much more proactive” and NHS officials did not seem to be keeping the non-executive members informed, let alone involved in decisions.

“I think the non-executive members of the board have to get their act together and have to assert their authority to make sure officials are doing what they should be doing on an ongoing basis,” he said.

Referring to the widely reported delay in informing health board members of the deaths, he added: “This includes keeping them informed when something as urgent and serious as this arises. It’s not acceptable that the non-executive members, who are supposed to monitor the performance of the health board, not just this hospital, wait a month before officials inform them and they end up hearing about these things through the media.

“They should be told immediately and if necessary an emergency meeting of the appropriate committee, in this case acute services, should have been called to make sure that everything that could have been done was being done.”

But Neil was quick to defend the concept of the “super-hospital”, saying that it wasn’t possible to deliver the quality of specialist centres of excellence without a centralised resource like this in Scotland.

“Now, I’m not saying ‘Build another one’, but I think we do need this hospital. It’s not just serving Glasgow – it’s serving the whole of Scotland.

“So I think it was absolutely the right thing to do because it’s a national resource not just a local one.

“This is second to none and is putting Scotland in the driving seat in terms of personalised medicine and that’s the future.”

Neil said there were a number of strands running through the original thinking behind the merging of four hospitals, three of which had been built in the Victorian era and were “no longer fit for purpose”.

“They were antiquated and the layout of them, which was almost impossible to change, was inefficient, and also there was no joined-up health provision.

“For example, young mothers who had given birth, if the mother and baby were ill they’d be in separate hospitals – it was a very disjointed service – really unacceptable for the 20th century, never mind the 21st century.”

Neil said there was never a serious alternative to building a super hospital for Glasgow if Scotland wanted to implement the best in modern medical practice. “We needed to consolidate specialisms so that we could build up these centres of excellence that are now within the hospital that were not there before,” he said.

“There was a need to build a hospital that will be transformational and would be able to accommodate the revolution that is taking place in medicine, for example in relation to personalised care.

“In five years’ time for example, if you have cancer and need chemotherapy – the treatment will not just be tailored to the DNA in your body – it will be tailored to the DNA in your tumour.”.

In her comment in response to the inquiry into the recent crisis Scotland’s Chief Medical Officer Catherine Calderwood praised Queen Elizabeth’s record of patient care and echoed Neil’s emphasis on the importance of investing in the most up-to-date facilities.

“Replacing older facilities with more modern ones plays an important role in enhancing access to the specialist treatment and services patients require. This is part of our whole-system approach, encompassing local community services and preventative care.

“Patient feedback tells us our NHS staff’s efforts are truly appreciated, thanks to hard-working staff providing high levels of care. The most recent Inpatient Experience Survey showed 87 per cent of patients rated their overall experience of the Queen Elizabeth University Hospital positively.

“Over the past four years £1.8 billion has been invested in new assets and facilities. And over the next three years our NHS is planning to invest a further £1.2 bn to maintain and further improve the NHS estate.”

Insisting that her thoughts were with the families of the patients who had died, Calderwood said: “Where issues are identified, such as these recent isolated infection cases, we are determined to act as quickly as possible to make improvements. That’s why the Scottish Government has asked the Healthcare Environment Inspectorate to investigate this incident, and are commissioning an external review into all potential contributory factors to ensure lessons are learnt.”

While the chief focus of concern about the pigeon faeces infection has been the design and construction of the building at Shieldhall itself, scrutiny is also bound to fall on working practices there and within the NHS as a whole.

Professor Michael S Griffin the president of the Royal College of Surgeons of Edinburgh (RSCEd) said the college had published a report in 2017 on ‘Improving the Working Environment for Safe Surgical Care’.

In it the College detailed a number of critical recommendations to support staff and enhance recruitment and retention through providing a positive working environment. But Griffin insisted patient safety was the core focus for all College activity and said a combination of simple steps made for a better future across hospitals and throughout the NHS.

The recommendations include re-establishing the traditional team structure; reintroducing a communal area, such as the hospital mess; supporting the extended surgical team; maximising training during daylight hours; minimising use of shift systems; providing rotas six to eight weeks in advance; providing recognition and job-planning for trainers; and providing a better title for junior doctors.

Willie Duffy, Unison regional organiser, is also concerned about working conditions at the hospital: “The recent events at the Queen Elizabeth Hospital in Glasgow, and the deaths of two patients, are a cause of great concern. Our thoughts are with the families at this difficult time.

“Unison fully supports a Scottish Government inquiry into the hospital. It’s particularly troubling that this could happen in such a new and costly hospital.

“We’re asking our members to provide any information they can to help the inquiry. We urge NHS Greater Glasgow and Clyde Health Board to conduct a full risk assessment to ensure patients and staff are safe.”

Meanwhile, Scottish Labour’s Monica Lennon said the tragic events of the past week had “rocked public trust” in the hospital and people needed answers about how the infections came about.

She added: “Establishing this review is the right thing to do and the Health Secretary must ensure that patients and families are listened to and have a role in the process. The review must also consider workforce challenges at the hospital, including whether appropriate staffing levels for maintenance and hygiene have been in place.

“This review must be fully transparent and robust but we also need to see urgent steps taken to restore confidence in the safety and reputation of Scotland’s flagship hospital.”