Queen Elizabeth University Hospital Timeline
2015:
In April 2015, Glasgow’s Queen Elizabeth University Hospital (QEUH) officially opened.
In advance of the QEUH’s opening, an independent risk assessment of water services was carried out. This identified a number of ‘high risk’ issues including:
- A lack of management structure.
- Breakdowns in communication.
- Problems with water temperature control.
It recommended for a management system to be put in place, background dosing of the water, and control of the water system.
Four years later, in November 2019, whistleblowers passed this report to Anas Sarwar.
The QEUH also opened with the ventilation derogation agreed by NHS Greater Glasgow & Clyde in 2009 – an air change rate of 2 of 3 per hour, less than half of the 7 changes required in guidance.
2017:
NHS staff first raised concerns, and an SBAR was sent to the chair and chief executives of NHS Greater Glasgow & Clyde regarding the ventilation derogation. Ward 4c was verified and found to be insufficient for immunocompromised patients.
In July of 2017, 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 took 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’ warned of a ‘limited knowledge’ of water systems among those in charge, and that the site (hospital) was ‘high risk’.
A series of 23 blood stream infections were identified in Ward 2A/B QEUH, and, in September 2018, Wards 2A/B were closed and all patients were transferred to Wards 4B and 6A .
In November, the water supply was shutdown to allow for chlorine dioxide dosing.
A report by health Protection Scotland was submitted (published in February 2019) which stated that:
“A number of lessons can be taken from this incident for NHSGGC [NHS Greater Glasgow & Clyde] and NHSScotland as a whole in relation to water safety and commission, handover and maintenance of buildings.”
2019:
In January, the Sun newspaper approached the health board seeking comment on a fungal infection at the QEUH. This revealed that two patients, including a 10-year-old in Ward 6A, died at the QEUH after contracting Cryptococcus (a fungal infection) caused by pigeon droppings. It was also revealed that the infection was first identified in November 2018, but the Scottish Government was only told in December.
Patient satisfaction continued to decline.
On 22nd January, Jeane Freeman – the Health Secretary at the time – announced an independent review into the fabric of the building. This review was carried out and reported 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, working/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 concluded that there were 10 cases in 2016 affecting 10 children and 26 cases in 2017 affecting 14 children, which were previously unreported. It found that 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 were passed to health chiefs, but were not made public.
In August, Ward 6A was closed to new admissions after three young patients contracted infections.
On 17th September, Jeane Freeman announced a public independent inquiry into the QEUH campus and the Children’s Hospital in Edinburgh, which was launched on 3 August 2020.
In November, Anas Sarwar received the independent risk assessment from 2015, warning about the risk of water contamination in the QEUH.
2020:
The QEUH’s general state continued to come under scrutiny.
In January, Jeane Freeman gave 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” 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 was reported to the Procurator Fiscal for investigation by the board – two and half years after she died.
In June, the independent review commissioned in January 2019, published its findings on the design, commissioning, and maintenance of the hospital. A BBC Disclosure Scotland documentary also revealed that a senior doctor’s attempts to raise concerns were not taken seriously.
In August, the Scottish Hospitals Public Inquiry commenced, investigating how issues relating to ventilation, water contamination, and other matters impacted on patient safety and care in both the QEUH and a Children’s Hospital in Edinburgh. It also aimed to determine whether the buildings were suitable environments to deliver safe care, and whether these issues could have been prevented.
In December 2020 the Oversight Board published an interim report with initial findings and recommendations, concluding that NHS Greater Glasgow & Clyde should “pursue more active and open transparency.”
2021:
In March, the Case Note review and final report of the Oversight Board were published.
The Case Note review found that, since 2015, “84 children and young people… experienced 118 episodes of infection”. At least 33 of these episodes “probably” related to the hospital environment, and two children and young people had died due to their infection.
The report from the Oversight Board concluded 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 weaknesses in governance and the relationships between IPC and other teams.
- The Board did not fully consider the legislative requirement to consider cases under the organisational duty of candour.
In total, 108 recommendations were made and it was recommended that the Board remain at Stage 4 on the performance escalation framework.
In September, evidence sessions for the public inquiry commenced and police confirmed that they were 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 aspergillus – a fungal infection – in the QEUH while 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 then revealed that there were 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. These cases were raised at FMQs by Anas Sarwar.
In response, the Health Secretary stated that he had full confidence in the health board implementing the recommendations made of them.
Scottish Labour brought a vote of no confidence in the health board’s Senior Management Team to parliament. It received the backing of opposition parties, but was voted down by the SNP and Green Government.
2023:
In November, NHS Greater Glasgow & Clyde was named as a suspect in a corporate homicide investigation.
2024:
Inquiry ongoing.
2025:
Glasgow Hearings and evidence sessions places took place.
In December, NHS Greater Glasgow & Clyde admitted that a material portion of the infections were likely related to environmental factors.
2026:
In January, the final hearings of the Inquiry took place in Edinburgh, with all parties submitting closing statements. Across the Inquiry, 186 witnesses took part.
The Inquiry’s report is expected later in the year.
The whole hospital ventilation system has still not been validated.