Public Inquiry
Vale of Leven Hospital Inquiry
Status: Completed
Chair: The Rt Hon Lord MacLean
Established: Aug 2009
Report: Nov 2014
Commissioned by: Scottish Government
The Vale of Leven Hospital Inquiry investigated the occurrence of Clostridium difficile infection at the Vale of Leven Hospital from 1 January 2007 onwards, particularly between 1 December 2007 and 1 June 2008, and the deaths associated with that infection. …
Response breakdown
Evidence & impact
The Vale of Leven Hospital Inquiry was established in November 2009 following an outbreak of Clostridium difficile infection at the hospital between December 2007 and June 2008. Lord MacLean's inquiry examined the circumstances surrounding the outbreak and made 75 recommendations in November 2014 aimed at preventing similar incidents.
The Scottish Government accepted all 75 recommendations. The government response describes various initiatives and frameworks already in place or subsequently developed that align with the inquiry's recommendations. These include the Healthcare Environment Inspectorate providing independent scrutiny of hospitals, the National Infection Prevention and Control Manual introduced in 2012, and revised Healthcare Associated Infection Standards published in 2015.
The response identifies reforms to professional standards, particularly the revised NMC code requiring improved record-keeping by nurses, and initiatives to enhance patient communication through the Person-centred Health and Care Collaborative. Investment in NHS infrastructure exceeded £400 million between 2014-2016, with formula-based funding for routine maintenance rising to £157.2 million in 2015/16.
Education and training initiatives include the Cleanliness Champions Programme completed by over 18,000 staff and accredited programmes for specialist roles. The Scottish Antimicrobial Prescribing Group works with NHS boards to maintain stewardship activities, supported by the Scottish Management of Antimicrobial Resistance Action Plan 2014-18.
However, no published evidence of progress updates or implementation reviews has been identified for any of the 75 recommendations since the inquiry reported. While the government response describes various relevant policies and frameworks, it does not provide specific evidence that certain key recommendations have been actioned, including giving HEI powers to close wards, establishing dedicated local HAI Task Forces, or implementing specific DNAR awareness initiatives. The absence of documented progress updates 11 years after publication raises questions about the extent to which the inquiry's recommendations have been systematically monitored and implemented.
The Scottish Government accepted all 75 recommendations. The government response describes various initiatives and frameworks already in place or subsequently developed that align with the inquiry's recommendations. These include the Healthcare Environment Inspectorate providing independent scrutiny of hospitals, the National Infection Prevention and Control Manual introduced in 2012, and revised Healthcare Associated Infection Standards published in 2015.
The response identifies reforms to professional standards, particularly the revised NMC code requiring improved record-keeping by nurses, and initiatives to enhance patient communication through the Person-centred Health and Care Collaborative. Investment in NHS infrastructure exceeded £400 million between 2014-2016, with formula-based funding for routine maintenance rising to £157.2 million in 2015/16.
Education and training initiatives include the Cleanliness Champions Programme completed by over 18,000 staff and accredited programmes for specialist roles. The Scottish Antimicrobial Prescribing Group works with NHS boards to maintain stewardship activities, supported by the Scottish Management of Antimicrobial Resistance Action Plan 2014-18.
However, no published evidence of progress updates or implementation reviews has been identified for any of the 75 recommendations since the inquiry reported. While the government response describes various relevant policies and frameworks, it does not provide specific evidence that certain key recommendations have been actioned, including giving HEI powers to close wards, establishing dedicated local HAI Task Forces, or implementing specific DNAR awareness initiatives. The absence of documented progress updates 11 years after publication raises questions about the extent to which the inquiry's recommendations have been systematically monitored and implemented.
Reports & milestones
Reports
24 Nov 2014
75 tracked recs
The Vale of Leven Hospital Inquiry Report
· Tracked recommendations
· PDF
Timeline
01 May 2009
Inquiry Announced
01 Nov 2009
Inquiry Establish…
24 Nov 2014
Final Report Publ…
Recommendations
| Code | Recommendation | Addressed to | Response | |
|---|---|---|---|---|
| R1 |
Scottish Government should ensure that the Healthcare Environment Inspectorate (HEI) has the power to close a ward to new admissions if the …
|
Scottish Government | Accepted | View → |
| R2 |
Scottish Government should ensure that policies and guidance on healthcare associated infection are accompanied by an implementation strategy and that implementation is …
|
Scottish Government | Accepted | View → |
| R3 |
Health Boards should ensure that infection prevention and control policies are reviewed promptly in response to any new policies or guidance issued …
|
NHS Health Boards (Scotland) | Accepted | View → |
| R4 |
Scottish Government should develop local healthcare Associated infection (HAI) Task Forces within each Health Board area.
|
Scottish Government | Accepted | View → |
| R5 |
Scottish Government should ensure that where any uncertainty over the future of any hospital or service exists, resolution of the uncertainty is …
|
Scottish Government | Accepted | View → |
| R6 |
Scottish Government should ensure that where major changes in patient services are planned there should be clear and effective plans in place …
|
Scottish Government | Accepted | View → |
| R7 |
In any major structural reorganisation in the NHS in Scotland a due diligence process including risk assessment, should be undertaken by the …
|
NHS Health Boards (Scotland) | Accepted | View → |
| R8 |
In any major structural reorganisation in the NHS in Scotland the Board or Boards responsible should ensure that an effective and stable …
|
NHS Health Boards (Scotland) | Accepted | View → |
| R9 |
Health Boards should ensure that infection prevention and control is explicitly considered at all clinical governance committee meetings from local level to …
|
NHS Health Boards (Scotland) | Accepted | View → |
| R10 |
Health Boards should ensure that patients diagnosed with CDI are given information by medical and nursing staff about their condition and prognosis.
|
NHS Health Boards (Scotland) | Accepted | View → |
| R11 |
Health Boards should ensure that patients, and relatives where appropriate, are made aware that CDI is a condition that can be life-threatening, …
|
NHS Health Boards (Scotland) | Accepted | View → |
| R12 |
Health Boards should ensure that when a patient has CDI patients and relatives are given clear and proper advice on the necessary …
|
NHS Health Boards (Scotland) | Accepted | View → |
| R13 |
Health Boards should ensure that there is a clear and effective line of professional responsibility between the ward and the Board.
|
NHS Health Boards (Scotland) | Accepted | View → |
| R14 |
Health Boards should ensure that the nurse in charge of each ward audits compliance with the duty to keep clear and contemporaneous …
|
NHS Health Boards (Scotland) | Accepted | View → |
| R15 |
Health Boards should ensure that nursing staff caring for a patient with CDI keep accurate records of patient observations including temperature, pulse, …
|
NHS Health Boards (Scotland) | Accepted | View → |
| R16 |
Health Boards should ensure that the nurse in charge of each ward reports suspected outbreaks of CDI (as defined in local guidance) …
|
NHS Health Boards (Scotland) | Accepted | View → |
| R17 |
Health Boards should ensure that where there is risk of cross infection, the nurse in charge of a ward has ultimate responsibility …
|
NHS Health Boards (Scotland) | Accepted | View → |
| R18 |
Health Boards should ensure that there is an agreed system of care planning in use in every ward with the appropriate documentation …
|
NHS Health Boards (Scotland) | Accepted | View → |
| R19 |
Health Boards should ensure that where Infection Control Nurses provide instructions on the management of patients those instructions are recorded in patient …
|
NHS Health Boards (Scotland) | Accepted | View → |
| R20 |
Health Boards should ensure that where a patient has, or is suspected of having, C.difficile diarrhoea a proper record of the patient's …
|
NHS Health Boards (Scotland) | Accepted | View → |
| R21 |
Health Boards should ensure that a member of nursing staff is available to deal with questions from relatives during visiting periods.
|
NHS Health Boards (Scotland) | Accepted | View → |
| R22 |
Health Boards should ensure that any discussion between a member of nursing staff and a relative about a patient which is relevant …
|
NHS Health Boards (Scotland) | Accepted | View → |
| R23 |
Health Boards should ensure that a nurse appointed as Tissue Viability Nurse (TVN) is appropriately trained and possesses, or is working towards, …
|
NHS Health Boards (Scotland) | Accepted | View → |
| R24 |
Health Boards should ensure that where a TVN is involved in caring for a patient there is a clear record in the …
|
NHS Health Boards (Scotland) | Accepted | View → |
| R25 |
Health Boards should ensure that every patient is assessed for risk of pressure damage on admission to hospital using a recognised tool …
|
NHS Health Boards (Scotland) | Accepted | View → |
| R26 |
Health Boards should ensure that where a patient has a wound or pressure damage there is clear documentation of the nature of …
|
NHS Health Boards (Scotland) | Accepted | View → |
| R27 |
Health Boards should ensure that where a patient requires positional changes nursing staff clearly record this on a turning chart or equivalent.
|
NHS Health Boards (Scotland) | Accepted | View → |
| R28 |
Health Boards should ensure that all patients have their nutritional status screened on admission to a ward using a recognised nutritional screening …
|
NHS Health Boards (Scotland) | Accepted | View → |
| R29 |
Health Boards should ensure that there is appropriate equipment in each ward to weigh all patients. Patients should be weighed on admission …
|
NHS Health Boards (Scotland) | Accepted | View → |
| R30 |
Health Boards should ensure that where patients require fluid monitoring as part of their critical care, nursing staff complete fluid balance charts …
|
NHS Health Boards (Scotland) | Accepted | View → |
| R31 |
Health Boards should ensure that the staffing and skills mix is appropriate for each ward, and that it is reviewed in response …
|
NHS Health Boards (Scotland) | Accepted | View → |
| R32 |
Health Boards should ensure that there is straightforward and timely escalation process for nurses to report concerns about staffing numbers/skill mix.
|
NHS Health Boards (Scotland) | Accepted | View → |
| R33 |
Health Boards should ensure that where a complaint is made about nursing practice on a ward this complaint is investigated by an …
|
NHS Health Boards (Scotland) | Accepted | View → |
| R34 |
Health Boards should ensure that changes in policy and/or guidance on antimicrobial practice issued by or on behalf of Scottish Government are …
|
NHS Health Boards (Scotland) | Accepted | View → |
| R35 |
Scottish Government should monitor the implementation of policies and/or guidance on antibiotic prescribing issued in connection with healthcare associated infection.
|
Scottish Government | Accepted | View → |
| R36 |
Health Boards should ensure that the level of medical staffing planned and provided is sufficient to provide safe high-quality care.
|
NHS Health Boards (Scotland) | Accepted | View → |
| R37 |
Health Boards should ensure that any patient with suspected CDI receives full clinical assessment by senior medical staff, that specific antibiotic therapy …
|
NHS Health Boards (Scotland) | Accepted | View → |
| R38 |
Health Boards should ensure that clear, accurate and legible patient records are kept by doctors, that records are seen as integral to …
|
NHS Health Boards (Scotland) | Accepted | View → |
| R39 |
Health Boards should ensure that medical and nursing staff are aware that a DNAR1 decision is an important aspect of care.
|
NHS Health Boards (Scotland) | Accepted | View → |
| R40 |
Health Boards should ensure that the key principles of prudent antibiotic prescribing are adhered to and that implementation of policy is rigorously …
|
NHS Health Boards (Scotland) | Accepted | View → |
| R41 |
Health Boards should ensure that there is no unnecessary delay in processing laboratory specimens, in reporting positive results and in commencing specific …
|
NHS Health Boards (Scotland) | Accepted | View → |
| R42 |
Health Boards should ensure that all those working in a healthcare setting have mandatory infection prevention control training that includes CDI on …
|
NHS Health Boards (Scotland) | Accepted | View → |
| R43 |
Health Boards should ensure that Infection Control Nurses and Infection Control Doctors have regular training in infection prevention and control of which …
|
NHS Health Boards (Scotland) | Accepted | View → |
| R44 |
Health Boards should ensure that performance appraisals of infection prevention and control staff take place at least annually.
|
NHS Health Boards (Scotland) | Accepted | View → |
| R45 |
Health Boards should ensure that where a manager has responsibility for oversight of infection prevention control, this is specified in the job …
|
NHS Health Boards (Scotland) | Accepted | View → |
| R46 |
Health Boards should ensure that the Infection Control Manager has direct responsibility for the infection prevention control service and its staff.
|
NHS Health Boards (Scotland) | Accepted | View → |
| R47 |
Health Boards should ensure that the Infection Control Manager reports direct to the Chief Executive or, at least, to an executive board …
|
NHS Health Boards (Scotland) | Accepted | View → |
| R48 |
Health Boards should ensure that the ICM is responsible for reporting to the Board on the state of HAI in the organisation.
|
NHS Health Boards (Scotland) | Accepted | View → |
| R49 |
Scottish Government should re-issue national guidance on the role of the ICM, stipulating that the ICM must be responsible for the management …
|
Scottish Government | Accepted | View → |
| R50 |
Health Boards should ensure that there is 24-hour cover for infection prevention and control seven days a week, and that contingency plans …
|
NHS Health Boards (Scotland) | Accepted | View → |
| R51 |
Health Boards should ensure that any Infection Control Team functions as a team, with clear lines of communication and regular meetings.
|
NHS Health Boards (Scotland) | Accepted | View → |
| R52 |
Health Boards should ensure that adherence to infection prevention and control polices, for example C. difficile and Loose Stools Policies, is audited …
|
NHS Health Boards (Scotland) | Accepted | View → |
| R53 |
Health Boards should ensure that surveillance systems are fit for purpose, are simple to use and monitor, and provide information on potential …
|
NHS Health Boards (Scotland) | Accepted | View → |
| R54 |
Health Boards should ensure that the users of surveillance systems are properly trained in their use and fully aware of how to …
|
NHS Health Boards (Scotland) | Accepted | View → |
| R55 |
Health Boards should ensure that numbers and rates of CDI are reported through each level of the organisation up to the Chief …
|
NHS Health Boards (Scotland) | Accepted | View → |
| R56 |
Health Boards should ensure that infection prevention and control groups meet at regular intervals and that there is appropriate reporting upwards through …
|
NHS Health Boards (Scotland) | Accepted | View → |
| R57 |
Health Boards should ensure that the minutes of all meetings and reports from each infection prevention and control committee are reported to …
|
NHS Health Boards (Scotland) | Accepted | View → |
| R58 |
Health Boards should ensure that there is lay representation at Board infection prevention and control committee level in keeping with local policy …
|
NHS Health Boards (Scotland) | Accepted | View → |
| R59 |
Health Boards should ensure that attendance by members of committees in the infection prevention and control structure is treated as a priority.
|
NHS Health Boards (Scotland) | Accepted | View → |
| R60 |
Health Boards should ensure that programmes designed to improve staff knowledge of good infection prevention and control practice, such as Cleanliness Champions …
|
NHS Health Boards (Scotland) | Accepted | View → |
| R61 |
Health Boards should ensure that unannounced inspections of clinical areas are conducted by senior infection prevention and control staff accompanied by lay …
|
NHS Health Boards (Scotland) | Accepted | View → |
| R62 |
Health Boards should ensure that senior managers accompanied by IPC staff visit clinical areas at least weekly to verify that proper attention …
|
NHS Health Boards (Scotland) | Accepted | View → |
| R63 |
Health Boards should ensure that there is effective isolation of any patient who is suspected of suffering from CDI, and that failure …
|
NHS Health Boards (Scotland) | Accepted | View → |
| R64 |
Health Boards should ensure that cohorting is not used as a substitute for single room isolation and is only resorted to in …
|
NHS Health Boards (Scotland) | Accepted | View → |
| R65 |
Health Boards should ensure that appropriate steps are taken to isolate patients with potentially infectious diarrhoea.
|
NHS Health Boards (Scotland) | Accepted | View → |
| R66 |
Health Boards should ensure that the healthcare environment does not compromise effective IPC, and that poor maintenance practices are not tolerated.
|
NHS Health Boards (Scotland) | Accepted | View → |
| R67 |
Health Boards should ensure that, where a local Link Nurse system is in place as part of the IPS system, the Link …
|
NHS Health Boards (Scotland) | Accepted | View → |
| R68 |
Health Boards should ensure that where a death occurs in hospital the consultant in charge of the patients care is involved in …
|
NHS Health Boards (Scotland) | Accepted | View → |
| R69 |
Health boards should ensure that if a patient dies with CDI either as a cause of death or as a condition contributing …
|
NHS Health Boards (Scotland) | Accepted | View → |
| R70 |
Crown Office and the Procurator Fiscal service (COPFS) should review its guidance on the reporting of deaths regularly and at least every …
|
COPFS | Accepted | View → |
| R71 |
Scottish Government should identify a national agency to undertake routine national monitoring of deaths related to CDI.
|
Scottish Government | Accepted | View → |
| R72 |
Health Boards should ensure that a non-executive Board Member or a representative from internal audit takes part in an Internal Investigation.
|
NHS Health Boards (Scotland) | Accepted | View → |
| R73 |
Health Boards should ensure that OCT3 reports provide sufficient details of the key factors in the spread of infection to allow a …
|
NHS Health Boards (Scotland) | Accepted | View → |
| R74 |
Scottish Government (whether through HPS, HIS, the HAI Task Force or otherwise) should as a matter of standard practice ensure that reports …
|
Scottish Government | Accepted | View → |
| R75 |
Health Boards should review such reports to determine what lessons can be learned and what reviews, audits or other measures (interim or …
|
NHS Health Boards (Scotland) | Accepted | View → |
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