December 3, 2021 Blog, Media

QEUH Scandal: A timeline summary

2015

In advance of the hospital opening in 2015 an independent risk assessment of water services was carried out. It identified a number of ‘high risk’ issues, including a lack of management structure, breakdowns in communication, and problems with water temperature control. It recommended background dosing of the water and a management system be put in place to manage and control the water system. This report was later leaked to Anas Sarwar. 

2017

NHS staff first raise concerns.

In July of this year Milly Main’s Hickman line was infected following a successful stem cell transplant. She died at the end of August with her death certificate listing four causes of death including “multi system organ failure possibly due to line sepsis due to Stenotrophomonas maltophilia”’.  In early August concerns about Stenotrophomas were raised and apparently escalated to Health Protection Scotland and the Scottish Government. 

An updated legionella risk assessment takes place and identified issues which are ‘high risk’. It also highlighted debris in a water tank that was first spotted in 2015, a filter system bypass which may have introduced bacteria in the system, and dirty water. A number of recommendations were once again made, including changing all shower heads. 

2018

An independent ‘gap analysis’ warns that the site is ‘high risk’.

In September, Wards 2A/B are closed and all patients are transferred to Wards 6A and 4B in the QEUH. In November the water supply is shutdown to allow for chlorine dioxide dosing. 

2019

In January it is revealed that two patients – including one a 10-year old in Ward 6A – at the QEUH have died after contracting a fungal infection, Cryptococcus, caused by pigeon droppings. The story is only revealed after the Sun newspaper approaches the health boards seeking comment on a fungal infection at the hospital. It is also later revealed that the infection was first identified in November but the Scottish Government was only told later in December.

Patient satisfaction continues to slide.

The then Health Secretary, Jeane Freeman, announces and independent review into the fabric of the building. This review is carried out and reports in June 2020.

In March, Health Protection Scotland published an inspection report of the QEUH. It found a number of issues with domestic staff vacancies, dysfunctional relationships in leadership groups – namely between facilities and infection control – and in the general maintenance of the estate. 

In July a clinician-led review of infection cases concludes there were 10 cases in 2016 affecting 10 children and 26 cases in 2017 affecting 14 children, which were previously unreported. It finds there were three deaths in 2017 involving patients who contracted an infection, with one death linked directly to the presence of Stenotrophomonas maltophilia in the patient. These findings are passed to health chiefs, but are not made public.

In August Ward 6A is closed to new admissions after three young patients contracted infections. 

2020

The Queen Elizabeth University Hospital’s general state continues to come under scrutiny.

In January, Jeane Freeman gives an update on the Oversight Board and announced the case note review. This was initiated to provide answers to families about their children’s experiences in the hospital since 2015. In The Scottish Parliament, she stated that she had “not ruled out level 5” (the highest escalation level) and that “that this is the final chance to respond appropriately to this level of escalation and direct Government involvement in direction. Either the board will respond to that or we will go to the next stage.” 

In February Milly Main’s death is reported to the Procurator Fiscal for investigation by the board – two and half years after she dies.

In June, the Independent Review publishes its findings on the design, commissioning and maintenance of the hospital. It finds that ambiguity and a lack of expertise and independent assurance impact the design and construction.

A BBC Disclosure Scotland documentary reveals a senior doctor’s attempts to raise the alarm were not taken seriously. 

In August, the Scottish Hospitals Public Inquiry is commenced.

In December, the Oversight Board published an interim report with initial findings and recommendations. 

2021

In March the Case Note review and final report of the Oversight Board are published. It found that since 2015, “84 children and young people between them experienced 118 episodes of infection”. At least 33 of these episodes probably related to the hospital environment and 2 children and young people had died due to their infection. 

The report from the Oversight Board concludes that: 

  • infection, prevention and control could have been improved, 
  • the strong possibility of a link between infections and water contamination was undeniable, 
  • the IPC approach was reactive and this was hampered by a lack of systemic processes to examine, record and then act on infections, 
  • there were weakness in governance and the relationships between IPC and other teams and, 
  • the Board did not fully consider the legislative requirement to consider cases under the organisational duty of candour. 

 

In September, evidence sessions for the public inquiry commence and police confirm that they are launching a criminal investigation into the death of Millie Main. 

In November, Louise Slorance made public the circumstances around the death of her husband Andrew Slorance who contracted Covid and then a fungal infection, aspergillus, in the QEUH while an inpatient to undergo cancer treatment. Louise Slorance was not told about the aspergillus infection and only discovered it when reading her husband’s medical notes after his death. 

Whistleblowers at the hospital reveal that there have been two further deaths of children due to infections related to the environment at the QEUH – one contracted aspergillus around the same time as Andrew Slorance whilst another child developed the same infection as Milly Main and died this year. These cases were raised at FMQs by Anas Sarwar.

The Health Secretary states that he has full confidence in the board who are implementing the recommendations made of them.

Scottish Labour bring a vote of no confidence in the health board’s Senior Management Team to parliament. It receives the backing of opposition parties but is voted down by the SNP and Green Government.