Patients with cancer were put at more risk because of design of Queen Elizabeth University Hospital, review finds

Patients with cancer were put at increased risk because of the design and build of the Queen Elizabeth University Hospital in Glasgow, an independent review has found.

While the Queen Elizabeth University Hospital Independent Review did not find clear evidence linking hospital deaths to failures in the design, build or maintenance of the hospital, it suggested that those who were immuno-suppressed were exposed to risks that could have been reduced with better design.

However, the report says that measures are now in place or under development at the Queen Elizabeth University Hospital (QEUH) and the adjoining Royal Hospital for Children (RHC) to reduce that risk.

“The QEUH and RHC combined have in place the modern safety features and systems that we would expect of a hospital of this type,” the report concludes, adding that the “general population of patients, staff and visitors can have confidence that the QEUH/RHC offers a setting for high quality healthcare.”

The independent review, which was led by Dr Andrew Fraser and Dr Brian Montgomery, was announced in February 2019 with the remit of investigating whether the management of the project to build the QUEH had adversely impacted on the risk of healthcare-associated infection. 

This followed concerns about the deaths of three patients between December 2018 and February 2019 which had been linked to rare microorganisms.

During the review, over 100 hours of interviews were conducted with medical staff within in NHS, contractors and some of the patients and families who have been affected and around 3,000 documents and reports were scrutinised.

Labour MSP Anas Sarwar has raised concerns that Kimberly Darroch, the mother of 10-year-old Milly Main, who died of an infection of the Hickman line – a catheter used to administer drugs – at the hospital in August 2017, was not among those interviewed.

Although the investigation did not find clear evidence linking the building project to the deaths, the review raises a number of concerns about the process of managing the build, including the need for more external expertise and greater uptake of internal expertise at key points in the design; insufficient independent scrutiny; project governance that did not take into account the scale, complexity and specialist nature of the building; and issues within the infection prevention and control (IP&C) leadership team.

A number of secondary problems as a result of the infections are also mentioned, including disruption of treatment for some groups of patients; additional workload for IP&C teams, clinical groups and management; diversion of resources and attention from the running of the hospital; and undermining the reputation of the hospital.

The report makes 63 recommendations and also sets out three areas for future research ahead of similar projects: air quality in clinical environments, water quality in clinical environments and the clinical significance of rare microorganisms.

Fraser said: “While the hospital provides a safe healthcare environment for patients, staff and visitors, as the review progressed our findings caused us to focus on those clinical places caring for children and adults with cancers, including leukaemias.

“These specific groups have been exposed to risk that could have been lower if the correct design, build and commissioning had taken place.

“The series of problems and influences that we have identified through the phases of the QEUH project has disrupted treatment for defined groups of patients, meant additional workload for infection prevention and control teams, many clinical groups and hospital management, and diverted resources and attention from the running of this large and complex facility.”

Montgomery added: “Our focus was on delivering a clinically focused, forward-looking report that sought both to understand the origins of the situation in Glasgow but more importantly to assess the current state of the hospital and identify learning applicable to future capital projects.

Jeane Freeman to deliver statement to parliament on QEUH

“We found a complex story with a variety of perspectives and views. 

“Undoubtedly and with hindsight, the health board, groups within it, and the design and build contractor could have reached different decisions and produced results that would have reduced infection risk.

“We have tried to concentrate on learning from the experience in a way that will avoid repetition of mistakes and enhance future projects.”

The Scottish Government will publish a formal response to the report’s findings and recommendations shortly, and there will also be a public inquiry into problems at the QEUH and similar issues at the Sick Kids in Edinburgh, but health secretary Jeane Freeman gave initial response to the report.

She said: “The patients and families most affected by the issues raised in the report will be understandably concerned and distressed by some of the findings of the independent review.  

“I have been clear that those who have been affected deserve answers to the many questions they are entitled to ask – and this review is an important step in delivering that.

“The report provides a wealth of information for the forthcoming public inquiry into the construction of the QEUH and the Royal Hospital for Children and Young People in Edinburgh for which the remit and terms of reference have now been published.

“In addition to the public inquiry, an oversight board, led by Scotland’s chief nursing officer, Fiona McQueen, will report on infection prevention and control practices at the hospital.

“We also await the results of a case note review of all recorded Gram-negative bloodstream infections in children who received haemato-oncology treatment from the opening of the Royal Hospital for Children in Glasgow until the start of this year.

“This team is also considering whether these children were put at risk because of the physical environment in which they were cared for.

“I would like to thank the review team for their diligence in carrying out this report and the hospital staff for their focus on providing high quality care throughout this challenging time.”

The Scottish Conservatives and Scottish Labour both described the report as “damning”.

Scottish Conservative shadow health secretary Miles Briggs said: “This is an explosive report which presents yet more questions regarding what SNP ministers knew and when.

“It very clearly concludes that patients young and old with cancer – the same group from which people died – were placed at increased risk because of the building and design of the hospital.

“That’s an utterly damning verdict on this SNP government which planned, commissioned and built this hospital.”

Scottish Labour's health spokesperson, Monica Lennon, said: “This damning report is deeply troubling.

“However, it is an important step towards getting the truth about the dangerous failings at the Queen Elizabeth University Hospital.

“Vulnerable patients were unnecessarily exposed to risks and they were let down by SNP ministers and the health board.

“This was supposed to be the SNP's flagship hospital and patients should have been safe there.”