Vale of Leven Hospital Inquiry

Scottish Government should ensure that the Healthcare Environment Inspectorate (HEI) has the power to close a ward to new admissions if the HEI concludes that there is a real risk to the safety of patients. In the event of such closure, an urgent action plan should be devised with the Infection Prevention and Control Team and management.

The Inquiry recommended giving inspectors the power to close hospital wards to new admissions. In a policy note of January 2016, the Scottish Government Healthcare Quality and Strategy Directorate stated that secondary legislation gives Healthcare Improvement Scotland (HIS) the power to direct health boards to close hospital wards if there is a serious risk (Scottish Government, Feb 2016). The directorate's note described ward closure powers, but the recommendation's requirement for an urgent action plan is not mentioned in the sources (Scottish Government, Feb 2016). Earlier, in June 2015, Shona Robison, the Cabinet Secretary for Health, Wellbeing and Sport, had informed the Scottish Parliament that work was underway to introduce legislation giving HIS those closure powers (Shona Robison, Jun 2015).

Scottish Government should ensure that policies and guidance on healthcare associated infection are accompanied by an implementation strategy and that implementation is monitored.

The Inquiry asked the Scottish Government to ensure infection guidance has a monitored implementation strategy. In its June 2015 response, it accepted responsibility for identified failings and stated that it accepted "in full all of the report's recommendations", though it did not detail an implementation strategy or monitoring for healthcare associated infection guidance (Scottish Government response, Jun 2015).

Health Boards should ensure that infection prevention and control policies are reviewed promptly in response to any new policies or guidance issued by or on behalf of the Scottish Government, and in any event at specific review dates no more than two years apart.

The Inquiry asked health boards to review infection prevention and control policies promptly and regularly. In June 2015, the Scottish Government stated in its formal response to the report that it accepted all of the inquiry's recommendations in full (Scottish Government response, Jun 2015). In the same response, it accepted responsibility for the failings identified in the report and apologised unreservedly for the suffering and loss caused (Scottish Government response, Jun 2015). The record holds nothing dated later than the response of June 2015 (Scottish Government response, Jun 2015).

Scottish Government should develop local Healthcare Associated Infection (HAI) Task Forces within each Health Board area.

The Inquiry recommended establishing local Healthcare Associated Infection task forces in each health board area. In June 2015, the Scottish Government accepted responsibility for the failings identified in the inquiry report and stated that it accepted "in full all of the report's recommendations", though it did not specifically mention creating local task forces (Scottish Government response, Jun 2015).

Scottish Government should ensure that where any uncertainty over the future of any hospital or service exists, resolution of the uncertainty is not delayed any longer than is essential for planning and consultation to take place.

The Inquiry recommended avoiding unnecessary delays in resolving uncertainty regarding hospital or service futures. In its response of June 2015, the Scottish Government apologised unreservedly for the suffering and loss caused, accepted responsibility for the failings identified in the report, and stated that it accepted "in full all of the report's recommendations" (Scottish Government response, Jun 2015).

Scottish Government should ensure that where major changes in patient services are planned there should be clear and effective plans in place for continuity of safe patient care during the period of planning and change.

The Inquiry asked the Scottish Government to ensure safe care continuity during major service changes. In June 2015, it stated that it accepted all recommendations in the report in full (Scottish Government response, Jun 2015). Plans for continuity of safe patient care during service changes are not mentioned in the sources (Scottish Government response, Jun 2015).

In any major structural reorganisation in the NHS in Scotland a due diligence process including risk assessment should be undertaken by the Board or Boards responsible for all patient services before the reorganisation takes place. Subsequent to that reorganisation regular reviews of the process should be conducted to assess its impact upon patient services, up to the point at which the new structure is fully operational. The review process should include an independent audit.

The Inquiry asked health boards to conduct due diligence before major structural reorganisations. The Scottish Government stated in June 2015 that it accepted all of the report's recommendations in full, but it did not describe action on risk assessments, regular reviews of patient services, or independent audits (Scottish Government response, Jun 2015).

In any major structural reorganisation in the NHS in Scotland the Board or Boards responsible should ensure that an effective and stable management structure is in place for the success of the project and the maintenance of patient safety throughout the process.

The Inquiry asked Scottish health boards to maintain stable management structures during major reorganisations. In June 2015, the Scottish Government accepted responsibility for the failings identified in the inquiry report, apologised unreservedly for the suffering and loss caused, and stated that it accepted "in full all of the report's recommendations" (Scottish Government response, Jun 2015).

Health Boards should ensure that infection prevention and control is explicitly considered at all clinical governance committee meetings from local level to Board level.

The Inquiry asked health boards to consider infection control at all clinical governance meetings. In June 2015, the Scottish Government accepted responsibility for the identified failings and stated that it accepted "in full all of the report's recommendations", without mentioning infection prevention and control or clinical governance committee meetings (Scottish Government response, Jun 2015).

Health Boards should ensure that patients diagnosed with CDI are given information by medical and nursing staff about their condition and prognosis. Patients should be told when there is a suspicion they have CDI, and when there is a definitive diagnosis. Where appropriate, relatives should also be involved.

The Inquiry asked health boards to provide patients and relatives with Clostridium difficile information. In June 2015, the Scottish Government stated that it accepted all of the report's recommendations in full (Scottish Government response, Jun 2015). Its response did not mention discussing condition prognosis, notifying patients of suspected or definitive diagnoses, or involving relatives (Scottish Government response, Jun 2015).

Health Boards should ensure that patients, and relatives where appropriate, are made aware that CDI is a condition that can be life-threatening, particularly in the elderly. The consultant in charge of a patient’s care should ensure that the patient and, where appropriate, relatives have reasonable access to fully informed medical staff.

The Inquiry asked Scottish health boards to communicate Clostridium difficile infection (CDI) risks. In June 2015, the Scottish Government stated that it accepted all recommendations in the report in full, but it did not mention informing patients and relatives that CDI can be life-threatening or ensuring access to medical staff (Scottish Government response, Jun 2015).

Health Boards should ensure that when a patient has CDI patients and relatives are given clear and proper advice on the necessary infection control precautions, particularly hand washing and laundry. Should it be necessary to request relatives to take soiled laundry home, the laundry should be bagged appropriately and clear instructions about washing should be given. Leaflets containing guidance should be provided, and these should be supplemented by discussion with patients and relatives.

The Inquiry asked health boards to provide clear infection control advice to patients. In June 2015, the Scottish Government stated that it accepted "in full all of the report's recommendations" and apologised for the suffering caused, but its response did not mention hand washing, laundry, or guidance leaflets (Scottish Government response, Jun 2015).

Health Boards should ensure that there is a clear and effective line of professional responsibility between the ward and the Board.

The Inquiry asked Scottish health boards to ensure clear professional responsibility from ward to board. National Health Service (NHS) Health Boards (Scotland) made no statement in the sources searched, though the Scottish Government stated in June 2015 that it accepted all of the report's recommendations in full, with a line of professional responsibility between the ward and the Board not mentioned in the sources (Scottish Government response, Jun 2015).

Health Boards should ensure that the nurse in charge of each ward audits compliance with the duty to keep clear and contemporaneous patient records. Health Boards should ensure that there is an effective system of audit of patient records, and that there is effective scrutiny of audits by the Board.

The Inquiry recommended that health boards audit ward compliance with clear patient records. In June 2015, the Scottish Government accepted responsibility for the failings and stated that it accepted "in full all of the report's recommendations" (Scottish Government response, Jun 2015). The response does not mention ward audits of record-keeping, an audit system, or board scrutiny (Scottish Government response, Jun 2015).

Health Boards should ensure that nursing staff caring for a patient with CDI keep accurate records of patient observations including temperature, pulse, respiration, oxygen saturation and blood pressure.

The Inquiry asked health boards to ensure accurate observation records for Clostridium difficile patients. In the June 2015 response to the inquiry report, the Scottish Government accepted responsibility for the failings identified in the report, apologised unreservedly for the suffering and loss caused, and confirmed that it accepted all recommendations in full (Scottish Government response, Jun 2015).

Health Boards should ensure that the nurse in charge of each ward reports suspected outbreaks of CDI (as defined in local guidance) to the Infection Control Team.

The Inquiry recommended that health boards ensure ward nurses report suspected infection outbreaks. In June 2015, the Scottish Government stated that it accepted "in full all of the report's recommendations" (Scottish Government response, Jun 2015). The response did not mention ward reporting of Clostridium difficile infection (CDI) outbreaks to infection control teams (Scottish Government response, Jun 2015).

Health Boards should ensure that where there is risk of cross infection, the nurse in charge of a ward has ultimate responsibility for admission of patients to the ward or bay. Any such decision should be based on a full report of the patient’s status and full discussion with site management, the bed manager, and a member of the Infection Control Team. The decision and the advice upon which the decision is based should be fully recorded contemporaneously.

The Inquiry asked health boards to give charge nurses authority over admissions during infection risks. In June 2015, the Scottish Government stated that it accepted "in full all of the report's recommendations", without detailing the admission procedures, multidisciplinary discussions, or contemporaneous record-keeping named in the recommendation (Scottish Government response, Jun 2015).

Health Boards should ensure that there is an agreed system of care planning in use in every ward with the appropriate documentation available to nursing staff. Where appropriate they should introduce pro forma care plans to assist nurses with care planning. Health Boards should ensure that there is a system of audit of care planning in place.

The Inquiry asked health boards to ensure agreed care planning systems, documentation, and audits. In June 2015, the Scottish Government stated that it accepted all inquiry recommendations in full, but it did not mention agreed ward care planning documentation, pro forma care plans, or audit systems (Scottish Government response, Jun 2015).

Health Boards should ensure that where Infection Control Nurses provide instructions on the management of patients those instructions are recorded in the patient notes and are included in care planning for the patient.

The Inquiry asked health boards to record infection control nurse instructions in patient notes. The Scottish Government stated in June 2015 that it accepted all of the report's recommendations in full, though the response did not mention recording infection control instructions in patient notes or care plans (Scottish Government response, Jun 2015).

Health Boards should ensure that where a patient has, or is suspected of having, C. difficile diarrhoea a proper record of the patient’s stools is kept. Health Boards should ensure that there is an appropriate form of charting of stools available to enable nursing staff to provide the date, time, size and nature of the stool. Stool charts should be continued after a patient has become asymptomatic of diarrhoea in order to reduce the risk of cross infection. Health Boards should ensure that all nursing staff are properly trained in the completion of these charts, and that the nurse in charge of the ward audits compliance.

The Inquiry asked health boards to keep, chart, and audit patients' stool records. In June 2015, the Scottish Government stated that it accepted "in full all of the report's recommendations", but its response did not mention stool charting, monitoring asymptomatic patients, nursing staff training, or ward compliance audits (Scottish Government response, Jun 2015).

Health Boards should ensure that a member of nursing staff is available to deal with questions from relatives during visiting periods.

The Inquiry asked Scottish health boards to provide nursing staff for relatives during hospital visits. In June 2015, the Scottish Government published its response to the Vale of Leven Hospital Inquiry Report, confirming that it accepted all of the recommendations in full (Scottish Government response, Jun 2015). In the response, it accepted responsibility for the failings identified by the inquiry and apologised unreservedly for the suffering and loss caused (Scottish Government response, Jun 2015). The record holds nothing dated later than the response of June 2015 (Scottish Government response, Jun 2015).

Health Boards should ensure that any discussion between a member of nursing staff and a relative about a patient which is relevant to the patient’s continuing care is recorded in the patient’s notes to ensure that those caring for the patient are aware of the information given.

The Inquiry asked health boards to record relevant nursing discussions with relatives in patient notes. In June 2015, the Scottish Government published its formal response to the Vale of Leven Hospital Inquiry Report, confirming that it accepted all of the report's recommendations in full (Scottish Government response, Jun 2015). It also stated that it accepted its responsibility for the failings identified in the report and apologised unreservedly for the suffering and loss caused (Scottish Government response, Jun 2015). The record holds nothing dated later than the response of June 2015 (Scottish Government response, Jun 2015).

Health Boards should ensure that a nurse appointed as Tissue Viability Nurse (TVN) is appropriately trained and possesses, or is working towards, a recognised specialist post-registration qualification. Health Boards should ensure that a trainee TVN is supervised by a qualified TVN.

The Inquiry asked health boards to ensure tissue viability nurses are trained and supervised. In June 2015, the Scottish Government stated that it accepted "in full all of the report's recommendations", but the response did not mention measures regarding training, specialist post-registration qualifications, or trainee supervision (Scottish Government response, Jun 2015).

Health Boards should ensure that where a TVN is involved in caring for a patient there is a clear record in the patient notes and care plan of the instructions given for management of the patient.

The Inquiry recommended recording tissue viability nurse instructions in patient care plans. In June 2015, the Scottish Government apologised for the failings identified in the inquiry report and stated that it accepted all of the report's recommendations in full, but its response did not mention recording instructions in patient notes or care plans (Scottish Government response, Jun 2015).

Health Boards should ensure that every patient is assessed for risk of pressure damage on admission to hospital using a recognised tool such as the Waterlow Score in accordance with best practice guidance. Where patients are identified as at risk they must be reassessed at the frequency identified by the risk scoring system employed. Compliance should be monitored by a system of audit.

The Inquiry recommended that Scottish health boards assess every patient for pressure damage risk. In June 2015, the Scottish Government responded to the report and stated that it accepted all recommendations in full (Scottish Government response, Jun 2015). The response did not mention admission risk assessments using a recognised tool, reassessment intervals, or monitoring compliance through audits (Scottish Government response, Jun 2015).

Health Boards should ensure that where a patient has a wound or pressure damage there is clear documentation of the nature of the wound or damage in accordance with best practice guidance, including the cause, grade, size and colour of the wound or damage. The pressure damage or wound should be reassessed regularly according to the patient’s condition. Compliance should be monitored by a system of audit.

The Inquiry asked health boards to document, regularly reassess and audit patient wounds. In June 2015, the Scottish Government stated that it accepted "all of the report's recommendations" in full, but it did not mention guidance on wound documentation, regular reassessments or audit systems (Scottish Government response, Jun 2015).

Health Boards should ensure that where a patient requires positional changes nursing staff clearly record this on a turning chart or equivalent. Compliance should be monitored by a system of audit.

The Inquiry recommended that Scottish health boards record patient positional changes and audit compliance. In June 2015, the Scottish Government confirmed in its response to the Vale of Leven Hospital Inquiry Report that it accepted all of the report's recommendations in full (Scottish Government response, Jun 2015). It also acknowledged its responsibility for the failings identified in the report and apologised unreservedly for the suffering and loss caused (Scottish Government response, Jun 2015). The record holds nothing dated later than the response of June 2015 (Scottish Government response, Jun 2015).

Health Boards should ensure that all patients have their nutritional status screened on admission to a ward using a recognised nutritional screening tool. Where nutritional problems are identified further assessment should be undertaken to determine an individual care plan. Appropriate and timely referrals should be made to dieticians for patients identified as being in need of specialist nutritional support.

The Inquiry recommended that health boards screen all patients for nutritional status on admission. In June 2015, the Scottish Government stated that it accepted in full all recommendations in the report (Scottish Government response, Jun 2015). That response did not mention recognised screening tools, individual care plans, or referrals to dieticians (Scottish Government response, Jun 2015).

Health Boards should ensure that there is appropriate equipment in each ward to weigh all patients. Patients should be weighed on admission and at least weekly thereafter and weights recorded. Faulty equipment should be repaired or replaced timeously and a contingency plan should be in place in the event of delays.

The Inquiry asked health boards to provide ward weighing equipment and record patient weights. In June 2015, the Scottish Government stated that it accepted "in full all of the report's recommendations" (Scottish Government response, Jun 2015). It did not mention ward weighing equipment, regular patient weighing, or contingency plans for faulty equipment (Scottish Government response, Jun 2015).

Health Boards should ensure that where patients require fluid monitoring as part of their clinical care, nursing staff complete fluid balance charts as accurately as possible and sign them off at the end of each 24-hour period.

The Inquiry recommended that nursing staff accurately complete and sign daily patient fluid balance charts. In June 2015, the Scottish Government stated that it accepted "in full all of the report's recommendations", but the response did not mention fluid balance monitoring or 24-hour chart sign-off (Scottish Government response, Jun 2015).

Health Boards should ensure that the staffing and skills mix is appropriate for each ward, and that it is reviewed in response to increases in the level of activity/patient acuity and dependency in the ward. Where the clinical profile of a group or ward of patients changes, (due to acuity and/or dependency) an agreed review framework and process should be in place to ensure that the appropriate skills base and resource requirements are easily provided.

The Inquiry asked health boards to review ward staffing and skills mix against patient needs. In June 2015, Shona Robison, Cabinet Secretary for Health, Wellbeing and Sport, stated to the Scottish Parliament that work was underway on workforce planning tools to address ward staffing ratios, skills mix, and changing acuity levels, but an agreed review framework and process was not mentioned (Shona Robison, Jun 2015).

Health Boards should ensure that there is a straightforward and timely escalation process for nurses to report concerns about the staffing numbers/skill mix.

The Inquiry recommended that health boards ensure straightforward and timely escalation of nurse staffing concerns. NHS Health Boards (Scotland) has stated no position on the recommendation, though the Scottish Government stated in June 2015 that it accepted in full all recommendations in the report (Scottish Government response, Jun 2015). A straightforward and timely escalation process for nurses to report staffing concerns is not mentioned in the source (Scottish Government response, Jun 2015).

Health Boards should ensure that where a complaint is made about nursing practice on a ward this complaint is investigated by an independent senior member of Nursing Management.

The Inquiry asked health boards to ensure independent senior nursing managers investigate ward nursing complaints. In June 2015, the Scottish Government accepted responsibility for the failings identified in the inquiry report and apologised unreservedly for the suffering and loss caused (Scottish Government response, Jun 2015). The government stated in its response to the Vale of Leven Hospital Inquiry Report that "We accept in full all of the report's recommendations" (Scottish Government response, Jun 2015). The record holds nothing dated later than the response of June 2015 (Scottish Government response, Jun 2015).

Health Boards should ensure that changes in policy and/or guidance on antimicrobial practice issued by or on behalf of Scottish Government are implemented without delay.

The Inquiry asked NHS health boards in Scotland to implement antimicrobial guidance without delay. In its formal June 2015 response to the Vale of Leven Hospital Inquiry Report, the Scottish Government accepted its responsibility for the failings identified in the report (Scottish Government response, Jun 2015). The department also apologised unreservedly for the suffering and loss caused, confirming that it accepted "in full all of the report's recommendations" (Scottish Government response, Jun 2015). The record holds nothing dated later than the response of June 2015 (Scottish Government response, Jun 2015).

Scottish Government should monitor the implementation of policies and/or guidance on antibiotic prescribing issued in connection with healthcare associated infection and seek assurance within specified time limits that implementation has taken place.

The Inquiry asked the Scottish Government to monitor antibiotic prescribing guidance and seek implementation assurances. In June 2015, it accepted responsibility for the identified failings and stated that it accepted "in full all of the report's recommendations" (Scottish Government response, Jun 2015). The response did not mention monitoring policies or seeking assurance within specified time limits (Scottish Government response, Jun 2015).

Health Boards should ensure that the level of medical staffing planned and provided is sufficient to provide safe high quality care.

The Inquiry asked health boards to ensure medical staffing levels provide safe care. In June 2015, the Scottish Government published its response to the inquiry report, stating that it accepted "in full all of the report's recommendations" (Scottish Government response, Jun 2015). That response does not mention medical staffing levels planned or provided by health boards (Scottish Government response, Jun 2015).

Health Boards should ensure that any patient with suspected CDI receives full clinical assessment by senior medical staff, that specific antibiotic therapy for CDI is commenced timeously and that the response to antibiotics is monitored on at least a daily basis.

The Inquiry recommended senior medical assessments and daily antibiotic monitoring for suspected Clostridium difficile infections. In June 2015, the Scottish Government stated that it accepted all of the report's recommendations in full, but its response did not mention senior clinical assessments, timeous antibiotic therapy, or daily monitoring (Scottish Government response, Jun 2015).

Health Boards should ensure that clear, accurate and legible patient records are kept by doctors, that records are seen as integral to good patient care, and that they are routinely audited by senior medical staff.

The Inquiry recommended that health boards ensure doctors maintain clear, regularly audited patient records. In June 2015, the Scottish Government stated that it accepted "in full all of the report's recommendations", though it did not detail specific measures on record legibility, auditing, or patient care (Scottish Government response, Jun 2015).

Health Boards should ensure that medical and nursing staff are aware that a DNAR decision is an important aspect of care. The decision should involve the patient where possible, nursing staff, the consultant in charge and, where appropriate, relatives. The decision should be fully documented, regularly reviewed and there should be regular auditing of compliance with the DNAR policy.

The Inquiry asked health boards to improve awareness, consultation, and auditing of resuscitation decisions. In June 2015, the Scottish Government stated that it accepted all of the report's recommendations in full (Scottish Government response, Jun 2015). Its statement does not mention staff awareness, patient involvement, documentation, regular reviews, or compliance audits (Scottish Government response, Jun 2015).

Health Boards should ensure that the key principles of prudent antibiotic prescribing are adhered to and that implementation of policy is rigorously monitored by management.

The Inquiry asked health boards to follow prudent antibiotic prescribing and monitor policy implementation. In June 2015, the Scottish Government stated that it accepted "in full all of the report's recommendations" (Scottish Government response, Jun 2015). The published response did not mention the principles of prudent antibiotic prescribing or management monitoring (Scottish Government response, Jun 2015).

Health Boards should ensure that there is no unnecessary delay in processing laboratory specimens, in reporting positive results and in commencing specific antibiotic treatment. Infection control staff should carry out regular audits to ensure that there are no unnecessary delays in the management of infected patients once the diagnosis is confirmed.

The Inquiry asked health boards to prevent delays in specimen processing and treatment. NHS Health Boards (Scotland) has made no statement on the recommendation, though the Scottish Government stated in June 2015 that it accepted "in full all of the report's recommendations" (Scottish Government response, Jun 2015). It did not mention specimen processing, reporting positive results, commencing antibiotic treatment, or infection control audits (Scottish Government response, Jun 2015).

Health Boards should ensure that all those working in a healthcare setting have mandatory infection prevention and control training that includes CDI on appointment and regularly thereafter. Staff records should be audited to ensure that such training has taken place.

The Inquiry recommended mandatory infection prevention training for healthcare staff and audits of records. In June 2015, the Scottish Government stated that it accepted "in full all of the report's recommendations", but it did not mention infection prevention training or auditing staff records (Scottish Government response, Jun 2015).

Health Boards should ensure that Infection Control Nurses and Infection Control Doctors have regular training in infection prevention and control, of which a record should be kept.

The Inquiry asked health boards to ensure and record regular infection control training. In June 2015, the Scottish Government stated that it accepted "in full all of the report's recommendations" (Scottish Government response, Jun 2015). It did not describe any action on training or record keeping for infection control nurses and doctors (Scottish Government response, Jun 2015).

Health Boards should ensure that performance appraisals of infection prevention and control staff take place at least annually. The appraisals of Infection Control Doctors who have other responsibilities should include specific reference to their Infection Control Doctor roles.

The Inquiry recommended annual performance appraisals for infection prevention and control staff. In June 2015, the Scottish Government stated in its response to the inquiry report that it accepted all recommendations in full, though it did not specifically mention infection prevention staff or infection control doctors (Scottish Government response, Jun 2015).

Health Boards should ensure that where a manager has responsibility for oversight of infection prevention and control, this is specified in the job description.

The Inquiry recommended that health boards specify infection control oversight in managerial job descriptions. In its June 2015 response to the inquiry report, the Scottish Government accepted responsibility for the failings identified, apologised unreservedly for the suffering and loss caused, and confirmed that it accepted "in full all of the report's recommendations" (Scottish Government response, Jun 2015). The response did not mention infection prevention and control oversight or managerial job descriptions (Scottish Government response, Jun 2015).

Health Boards should ensure that the Infection Control Manager has direct responsibility for the infection prevention and control service and its staff.

The Inquiry asked health boards to give infection control managers direct responsibility over their staff. In June 2015, the Scottish Government stated that it accepted "in full all of the report's recommendations" and apologised for the failings identified (Scottish Government response, Jun 2015). Direct responsibility for the infection prevention and control service and its staff is not mentioned in the source (Scottish Government response, Jun 2015).

Health Boards should ensure that the Infection Control Manager reports direct to the Chief Executive, or at least to an executive board member.

The Inquiry asked that infection control managers report directly to health board chief executives. Relaying the position for NHS Health Boards (Scotland), the Scottish Government stated in June 2015 that it accepted "in full all of the report's recommendations" (Scottish Government response, Jun 2015). The department apologised unreservedly for the suffering and loss caused, though it did not specifically mention reporting lines to chief executives or board members (Scottish Government response, Jun 2015).

Health Boards should ensure that the Infection Control Manager is responsible for reporting to the Board on the state of healthcare associated infection in the organisation.

The Inquiry asked health boards to ensure infection control managers report to them on infections. Relaying the position for NHS Health Boards (Scotland) in June 2015, the Scottish Government stated that it accepted "in full all of the report's recommendations", but did not mention Infection Control Managers or reporting on healthcare associated infections (Scottish Government response, Jun 2015).

Scottish Government should re-issue national guidance on the role of the Infection Control Manager, stipulating that the Infection Control Manager must be responsible for the management of the infection prevention and control service.

The Inquiry asked the Scottish Government to reissue national guidance on infection control managers. In June 2015, it stated that it accepted "in full all of the report's recommendations", though its response did not mention reissuing guidance or stipulating responsibility for managing the infection prevention and control service (Scottish Government response, Jun 2015).

Health Boards should ensure that there is 24-hour cover for infection prevention and control seven days a week, and that contingency plans for leave and sickness absence are in place.

The Inquiry asked health boards to provide continuous infection prevention and control cover. In June 2015, the Scottish Government stated that it did "accept in full all of the report's recommendations" (Scottish Government response, Jun 2015). Neither 24-hour cover seven days a week nor contingency plans for leave and sickness absence are mentioned in the sources (Scottish Government response, Jun 2015).

Health Boards should ensure that any Infection Control Team functions as a team, with clear lines of communication and regular meetings.

The Inquiry asked health boards to ensure infection control teams communicate and meet regularly. In June 2015, the Scottish Government accepted responsibility for the failings identified in the report, apologised unreservedly for the suffering and loss caused, and stated, "We accept in full all of the report's recommendations" (Scottish Government response, Jun 2015).

Health Boards should ensure that adherence to infection prevention and control policies, for example the C. difficile and Loose Stool Policies, is audited at least annually, and that serious non-adherence is reported to the Board.

The Inquiry asked for annual audits of infection prevention and control policy adherence. In June 2015, the Scottish Government stated that it accepted "in full all of the report's recommendations", without mentioning annual audits, policies on Clostridium difficile and loose stools, or reporting serious non-adherence to boards (Scottish Government response, Jun 2015).

Health Boards should ensure that surveillance systems are fit for purpose, are simple to use and monitor, and provide information on potential outbreaks in real time.

The Inquiry asked health boards to maintain real-time surveillance systems for potential outbreaks. In June 2015, the Scottish Government stated that it accepted all recommendations in the report in full (Scottish Government response, Jun 2015). Its response did not describe specific actions regarding systems that are simple to monitor or provide real-time information (Scottish Government response, Jun 2015).

Health Boards should ensure that the users of surveillance systems are properly trained in their use and fully aware of how to use and respond to the data available.

The Inquiry recommended that Scottish health boards ensure surveillance system users are properly trained. In June 2015, the Scottish Government stated that it accepted all recommendations from the report in full, but the response did not describe training in surveillance systems or how to respond to data (Scottish Government response, Jun 2015).

Health Boards should ensure that numbers and rates of CDI are reported through each level of the organisation up to the level of the Chief Executive and the Board. Reporting should include positive reporting in addition to any exception reporting. The Chief Executive should sign off the figures to confirm that there is oversight of infection prevention and control at that level.

The Inquiry recommended reporting Clostridium difficile infection (CDI) figures through organisations to health boards. In June 2015, the Scottish Government stated that it accepted all of the report's recommendations in full, but its response did not mention positive reporting, exception reporting, or sign-off by chief executives to confirm infection control oversight (Scottish Government response, Jun 2015).

Health Boards should ensure that infection prevention and control groups meet at regular intervals and that there is appropriate reporting upwards through the management structure.

The Inquiry recommended that health boards ensure regular infection control meetings and upward reporting. In June 2015, the Scottish Government stated that it accepted all of the report's recommendations in full, but the response did not mention infection prevention and control groups or upward management reporting (Scottish Government response, Jun 2015).

Health Boards should ensure that the minutes of all meetings and reports from each infection prevention and control committee are reported to the level above in the hierarchy and include the numbers and rates of CDI, audit reports, and training reports.

The Inquiry asked health boards to report infection control committee minutes and data hierarchically. NHS Health Boards (Scotland) has made no statement on the recommendation in the sources searched, but in June 2015 the Scottish Government stated that "We accept in full all of the report's recommendations" (Scottish Government response, Jun 2015). That response did not mention infection prevention and control committee minutes, Clostridium difficile infection (CDI) numbers or rates, audit reports, or training reports (Scottish Government response, Jun 2015).

Health Boards should ensure that there is lay representation at Board infection prevention and control committee level in keeping with local policy on public involvement.

The Inquiry asked Scottish health boards to include lay representation on infection control committees. In June 2015, the Scottish Government stated that it accepted all of the report's recommendations in full (Scottish Government response, Jun 2015). Lay representation on infection prevention and control committees was not mentioned in the source (Scottish Government response, Jun 2015).

Health Boards should ensure that attendance by members of committees in the infection prevention and control structure is treated as a priority. Non-attendance should only be justified by illness or leave or if there is a risk of compromise to other clinical duties in which event deputies should attend where practicable.

The Inquiry asked Scottish health boards to prioritise attendance at infection prevention meetings. NHS Health Boards (Scotland) has no statement on the record, though in June 2015 the Scottish Government stated that it accepted all inquiry recommendations in full (Scottish Government response, Jun 2015). That response did not mention committee attendance, permitted reasons for absence, or the appointment of deputies (Scottish Government response, Jun 2015).

Health Boards should ensure that programmes designed to improve staff knowledge of good infection prevention and control practice, such as the Cleanliness Champions Programme, are implemented without undue delay. Staff should be given protected time by managers to complete such programmes.

The Inquiry asked Scottish health boards to provide infection control training with protected staff time. In June 2015, the Scottish Government stated that it accepted "in full all of the report's recommendations", though neither the Cleanliness Champions Programme nor protected staff time was mentioned (Scottish Government response, Jun 2015).

Health Boards should ensure that unannounced inspections of clinical areas are conducted by senior infection prevention and control staff accompanied by lay representation to examine infection prevention and control arrangements, including policy implementation and cleanliness.

The Inquiry recommended unannounced infection control inspections of clinical areas accompanied by lay representatives. In June 2015, the Scottish Government stated that it accepted "in full all of the report's recommendations", but its response did not specifically address unannounced inspections, lay representation, policy implementation, or cleanliness in clinical areas (Scottish Government response, Jun 2015).

Health Boards should ensure that senior managers accompanied by infection prevention and control staff visit clinical areas at least weekly to verify that proper attention is being paid to infection prevention and control.

The recommendation asks that senior managers conduct weekly infection control visits to clinical areas. In June 2015, the Scottish Government accepted responsibility for the failings identified in the inquiry report and apologised for the suffering caused (Scottish Government response, Jun 2015). The department stated that it accepted all inquiry recommendations in full, though weekly clinical visits were not mentioned in the source (Scottish Government response, Jun 2015).

Health Boards should ensure that there is effective isolation of any patient who is suspected of suffering from CDI, and that failure to isolate is reported to senior management.

The Inquiry asked health boards to isolate suspected Clostridium difficile patients and report failures. In June 2015, the Scottish Government stated that it accepted all of the report's recommendations in full, but its response did not mention patient isolation or reporting failures to senior management (Scottish Government response, Jun 2015).

Health Boards should ensure that cohorting is not used as a substitute for single room isolation and is only resorted to in exceptional circumstances and under strict conditions of dedicated nursing, with infected patients nursed in cohort bays with en-suite facilities.

The Inquiry asked that patient cohorting be restricted to exceptional circumstances. Relaying the position for National Health Service (NHS) Health Boards (Scotland) in June 2015, the Scottish Government stated that "We accept in full all of the report's recommendations", without mentioning single room isolation, dedicated nursing, or en-suite facilities (Scottish Government response, Jun 2015).

Health Boards should ensure that appropriate steps are taken to isolate patients with potentially infectious diarrhoea.

The Inquiry asked Scottish NHS health boards to isolate patients with potentially infectious diarrhoea. Relaying the position for NHS Health Boards (Scotland), the Scottish Government stated in June 2015 that it accepted "in full all of the report's recommendations", though steps to isolate patients were not mentioned (Scottish Government response, Jun 2015).

Health Boards should ensure that the healthcare environment does not compromise effective infection prevention and control, and that poor maintenance practices, such as the acceptance of non-intact surfaces that could compromise effective infection prevention and control practice, are not tolerated.

The Inquiry asked Scottish health boards to ensure poor maintenance does not compromise infection control. In June 2015, the Scottish Government published its response to the inquiry report, stating that it accepted in full all of the report's recommendations (Scottish Government response, Jun 2015). In that response, it accepted responsibility for the failings identified in the report and apologised unreservedly for the suffering and loss caused (Scottish Government response, Jun 2015). The record holds nothing dated later than the response of June 2015 (Scottish Government response, Jun 2015).

Health Boards should ensure that, where a local Link Nurse system is in place as part of the infection prevention and control system, the Link Nurses have specific training for that role. The role should be written into job descriptions and job plans. They should have clear objectives set annually and have protected time for Link Nurse duties.

The Inquiry asked health boards to give link nurses specific training and protected time. In June 2015, the Scottish Government stated that it accepted all of the report's recommendations in full (Scottish Government response, Jun 2015). That statement did not mention role-specific training, job descriptions, annual objectives, or protected time for link nurse duties (Scottish Government response, Jun 2015).

Health Boards should ensure that where a death occurs in hospital the consultant in charge of the patient’s care is involved in the completion of the death certificate wherever practicable, and that such involvement is clearly recorded in the patient records. Regular auditing of this process should take place.

The Inquiry asked health boards to involve consultants in completing hospital death certificates. In June 2015, the Scottish Government stated that it accepted all of the report's recommendations in full (Scottish Government response, Jun 2015). That response did not mention consultant involvement in death certification, recording such involvement in patient records, or regular auditing (Scottish Government response, Jun 2015).

Health Boards should ensure that if a patient dies with CDI either as a cause of death or as a condition contributing to the death, relatives are provided with a clear explanation of the role played by CDI in the patient’s death.

The Inquiry asked health boards to explain Clostridium difficile infection (CDI) deaths to relatives. In June 2015, the Scottish Government accepted responsibility for failings identified in the inquiry report, apologised unreservedly for the suffering caused, and stated that "we accept in full all of the report's recommendations" (Scottish Government response, Jun 2015). The published response did not mention health boards providing explanations to relatives or addressing cases where CDI was a contributing condition (Scottish Government response, Jun 2015). The record holds nothing dated later than the response of June 2015 (Scottish Government response, Jun 2015).

Crown Office and the Procurator Fiscal Service (COPFS) should review its guidance on the reporting of deaths regularly and at least every two years.

The Inquiry asked prosecutors to review death reporting guidance at least every two years. In June 2015, the Scottish Government stated that it accepted in full all of the report's recommendations (Scottish Government response, Jun 2015). Regular reviews of guidance on the reporting of deaths by the Crown Office and Procurator Fiscal Service (COPFS) are not mentioned in the sources (Scottish Government response, Jun 2015).

Scottish Government should identify a national agency to undertake routine national monitoring of deaths related to CDI.

The Inquiry recommended identifying a national agency to monitor Clostridium difficile infection (CDI) deaths. In June 2015, the Scottish Government stated that it accepted all inquiry recommendations in full, but its response did not describe identifying an agency to undertake routine national monitoring of deaths related to CDI (Scottish Government response, Jun 2015).

Health Boards should ensure that a non-executive Board member or a representative from internal audit takes part in an Internal Investigation of the kind instigated by NHSGGC.

The Inquiry asked health boards to include non-executive directors or internal audit in investigations. In June 2015, the Scottish Government published its formal response to the Vale of Leven Hospital Inquiry report, stating that it accepted all recommendations in full (Scottish Government response, Jun 2015). In the same June 2015 document, it accepted responsibility for the failings identified by the inquiry and apologised unreservedly for the suffering and loss caused (Scottish Government response, Jun 2015). The record holds nothing dated later than the response of June 2015 (Scottish Government response, Jun 2015).

Health Boards should ensure that OCT reports provide sufficient details of the key factors in the spread of infection to allow a proper audit to be carried out, as recommended in the Watt Group Report.

The Inquiry asked health boards to ensure outbreak reports provide sufficient detail on infection spread. In June 2015, the Scottish Government published its formal response to the Vale of Leven Hospital Inquiry report, accepting responsibility for the failings identified in the findings (Scottish Government response, Jun 2015). It stated that it apologised unreservedly for the suffering and loss caused and confirmed that it accepted in full all of the report's recommendations (Scottish Government response, Jun 2015). The record holds nothing dated later than the response of June 2015 (Scottish Government response, Jun 2015).

Scottish Government (whether through HPS, HIS, the HAI Task Force or otherwise) should as a matter of standard practice ensure that reports published in the United Kingdom and in other relevant jurisdictions on infection prevention and control and patient safety are reviewed as soon as possible, and that, as a minimum, any necessary interim guidance is issued within three months.

The Inquiry recommended reviewing outside infection control reports and issuing timely interim guidance. In June 2015, the Scottish Government stated that it accepted "in full all of the report's recommendations" (Scottish Government response, Jun 2015). Its response did not mention reviewing external reports or publishing interim guidance within three months (Scottish Government response, Jun 2015).

Health Boards should review such reports to determine what lessons can be learned and what reviews, audits or other measures (interim or otherwise) should be put in place in the light of these lessons.

The Inquiry asked health boards to review infection reports to identify lessons and measures. In June 2015, the Scottish Government stated that it accepted "in full all of the report's recommendations", though reviews, audits, or other measures are not mentioned in the source (Scottish Government response, Jun 2015).