GRIEVING MUM: WE’RE LEFT IN THE DARK
Heartbroken mother of Milly Main hits out as a damning hospital report fails to provide answers about daughter’s death
A HEARTBROKEN mum whose daughter died after getting an infection at Scotland’s £842million superhospital has hit out after a damning report said design flaws put patients at risk. The review into Glasgow’s Queen Elizabeth University Hospital and the Royal Hospital for Children found the construction and design of the building caused at least 38 patients – mainly children – to become infected. Kimberly Darroch, 36, whose daughter Milly Main died in August 2017 after picking up an infection at the RHC while recovering from leukaemia, said the report did not do enough to allay the fears of patients over deaths. And she claimed she is “still in the dark” about her daughter’s case after the report said they could find no evidence that the design flaws were linked to deaths. The review, chaired by Dr Andrew Fraser and Dr Brian Montgomery, judged that the hospitals were not built in a manner that took full account of the needs of vulnerable patients and their families. Kimberly, from Lanark, said: “We weren’t spoken to as part of the review but we hoped it might help us understand more about why Milly contracted an infection. We feel we’re still in the dark.
“I don’t understand how they can claim there is no evidence linking failures in the hospital design to avoidable deaths.
“I don’t feel the report has restored any trust in the health board.”
First Minister Nicola Sturgeon yesterday insisted Kimberly and other parents would get answers in an upcoming inquiry into the hospital.
She added that there was “a determination to make sure they get answers as far as that is possible. That’s why the public inquiry, which this report will feed into, is so important”.
The review was commissioned following an outcry over the deaths of
three patients between December 2018 and February 2019. The deaths had been linked to rare microorganisms and concern was growing that the organisms were linked to the buildings’ design.
Two of the deaths happened after patients – one woman and one child – developed cryptococcus.
The third death, of gran Mito Kaur, was linked to a separate mucor infection.
The review spoke to the families of the two deaths linked to cryptococcus but the authors said Mito’s family did not engage with the review.
Part of the review examined whether downdraught from helicopters landing on the hospital roof could have disturbed pigeon droppings and blown them into the ventilation system.
No evidence was found of that and the review failed to establish if pigeon droppings were the cause of the infection, pointing out that the bug also occurs in the “atmosphere”.
The report drew attention to a water risk assessment in April 2015, when the hospital was handed over to NHS Greater Glasgow and Clyde, which rated the risk as “high” – and made recommendations not acted upon by the time of a follow-up report in 2017.
Montgomery said: “That report highlighted a number of significant problems but no action appears to have been taken on the back of it.
“The follow-up report two years later reported the exact same issues. Had the first report been acted on, a lot of the issues we have identified could have been dealt with earlier.
“It appears that report was passed to an individual and either it was missed or no proceedings taken.
“We haven’t managed to get a satisfactory answer to that.”
However, the report did find that “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”.
The report flagged up that patients, staff and visitors with immune system issues or who were in proximity to patients with infectious diseases, were exposed to risk “that could have been lower if the correct design, build and commissioning had taken place”.
And it criticised the health board for failing to tap into the expertise of its staff when it came to ventilation and water systems.
It said: “There was a pattern of individuals with technical and engineering knowledge of the issues with an impact on infection prevention and control available in-house offering assistance and either being declined, ignored or told not to interfere.”
The review found there were unintended consequences of the single room policy, which included the risk of water stagnation associated with low of use of the high number of taps and sinks. Other criticisms involved the mechanical ventilation system which did not achieve the number of air changes per hour specified in guidance, problems with the combined heat and power plant resulting in hot water temperatures below recommended levels for bacterial growth and openended pipes wide enough to allow rodents inside.
But the authors said the overriding problem was a “lack of quality assurance”. Montgomery commented: “There was not enough checking at various stages throughout the project that everything was as it should be.”
Labour MSP Anas Sarwar said the report “falls short of being a truly independent inquiry”.
He called it a “first step towards understanding the scale of the scandal, and the catastrophic errors which took place” but said there was still a lot of work to do to uncover the full truth.
He said: “This report looks to the future and appears to be an attempt to protect reputations.”
Sarwar said he would not stop until there was justice for Milly’s parents but Fraser and Montgomery said he was contacted by the review team and chose not to get involved.
Labour health spokeswoman Monica Lennon called the report “deeply troubling”. She added: “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.”
Scottish Conservative health spokesman Miles Briggs said the “explosive” report concludes that patients “young and old with cancer were placed at increased risk because of the building and design of the hospital”.
NHSGGC chief executive Jane Grant said: “This has been a very difficult period for our patients, their families and our staff for which we apologise.
“The findings highlight several areas of learning for NHSGGC. We remain fully committed to applying the learning from this experience.
“We remain focused on remedying any ongoing consequences of decisions and actions taken when designing, building and commissioning of the hospitals and in their maintenance.
“The report highlights issues concerning previous ways of working in one area of the board with regard to infection prevention and control.
“We recognise that there are still issues to be addressed concerning the organisation’s culture.”
The board also said that all patients and their families had been invited to participate in the report, despite claims by Milly’s family that they were not spoken to.
I don’t feel the report has restored any trust in the board
KIMBERLY DARROCH