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

75 recommendations total
100%
75 (100%)Accepted

Evidence & impact

AI-generated · 26 Mar 2026
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.

Reports & milestones

Reports

Timeline

01 May 2009 Inquiry Announced
01 Nov 2009 Inquiry Establish…
24 Nov 2014 Final Report Publ…

Recommendations

75 shown
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 →

Parliamentary activity

7 mentions since Jun 2016
18 Jun 2026 Early Day Motion West Dunbartonshire Schools Golf Championship
Douglas McAllister (Labour)
13 Apr 2026 Early Day Motion Greenwheel Electric electric vehicle charging and business hub
Douglas McAllister (Labour)
05 Sep 2023 Early Day Motion Emma Dean, Dance World Cup
Kirsten Oswald (Scottish National Party)
18 Apr 2023 Early Day Motion Red Ramp Events and the Golden Friendship Club
Martin Docherty-Hughes (Scottish National Party)
08 Sep 2021 Early Day Motion 50 years of West Dunbartonshire Citizens Advice Bureau
Martin Docherty-Hughes (Scottish National Party)
View all 7 mentions →