2. Terms of Reference
In March 2016, Pauline Neilson, guidance lecturer for
Access b Humanities set the class the task of producing a
local investigation. This project would be in the form of a
booklet and will detail a significant event or time in the
local area.
It will use available resources of witnesses, newspapers
and the internet to describe the event as it happened
and also how it affected the local community in the long
term.
It will conclude by detailing any changes this event
achieved both locally and nationally.
This local investigation is going to look at the families
who fought for a public inquiry into their loved ones
deaths after an outbreak of a hospital acquired infection,
Clostridium difficile, at the Vale of Leven Hospital
3. Contents
1. Terms of reference
2. Contents
3. Introduction
4. What is Clostridium Difficile
5. The Vale of Leven Hospital
6. The Families Fight begins
7. The inquiry begins
8. Did the families get their answers?
9. A word from others
10. Conclusion
11. References
4.
5. Introduction
Between December 2007 and June 2008 the Vale of
Leven hospital had not only the threat of closure hanging
over it there was a bacterium spreading throughout its
wards infecting the patients at an alarming rate.
No one knew, nothing flagged it up, no outbreak
procedures were implemented, no infection specialists
were brought in. This bacteria was left to do its worst.
In May 2008 after a story in a local paper brought 3
cases to light the Greater Glasgow and Clyde health
board proceeded to do a lookback exercise to
understand what had happened.
Families of victims of the infection had also seen the
story and started coming forward with their stories and
thus the C-Diff Justice Group was born. What follows is
their fight for answers and the hope lessons would be
learned.
6. What is Clostridium Difficile?
Clostridium Difficile (c-diff) is a bacterium that causes an
infection of the bowel. The infection is most common in
hospitals or nursing homes and can be triggered by the
use of antibiotics. The symptoms can range from
diarrhea to colitis(inflammation of the colon).
There are many different types of C-Difficile as it has
evolved and became more virulent and harder to treat.
The strain that was identified at the Vale of Leven
hospital was the 027, this is a strain that is hard to
eradicate from the environment, hard to treat and can
be fatal.
7. The Vale of Leven Hospital
2
The Vale of Leven Hospital opened in August 1955 and
was set in the heart of Alexandria. It serves the people of
West Dunbartonshire, Helensburgh and the Lochside.
Over time services that have been offered at the Vale
Hospital have diminished and when it came under the
management of Greater Glasgow and Clyde Health Board
(GGCHB) a lot of its services transferred to the Royal
Alexandria in Paisley.
8. This led to a time of uncertainty for its future and a lack
of investment into services and the fabric of the building.
After the C-difficile outbreak was exposed it brought to
light the fact the hospital was running under a dark cloud
of worry. Staff worrying about their jobs, patients
worrying about their access to health care and the Health
Board worrying about what to do with the Vale.
Between October 2008 and January 2009 GGCHB went
out to public consultation on the future of services at the
Vale Hospital.
The results of the consultation were reviewed by the
Health Board and in February 2009 they put their
recommendations forward to the Cabinet Secretary for
Health and Wellbeing.
The Cabinet Secretary confirmed her support to end the
uncertainty at the vale and fully support the Boards
"Vision for the Vale"
9. The Families Fight Begins.
After the outbreak came to light, in early June 2008 the
families came together with the help of their local MSP
Jackie Baillie. After talking through each families
experiences they believed that systems at the Vale
hospital had failed them and they decided that to get the
answers to why they would campaign for a public inquiry.
They then formed the C-Diff Justice Group to fight for the
answers for their loved ones and to ensure lessons were
learned from the outbreak.
10. The first thing the families did was interview and appoint
Patrick McGuire from Thompsons as the lawyer to
represent them.The families then used numerous
methods available to them to campaign to the Scottish
Parliament in order to achieve their ultimate goal of a
Public Inquiry.
Their MSP put a motion forward in their name to be
debated in the chambers, the families attended Holyrood
that day and listened to the MSP,s debate the issue and
afterward met with all parties Health spokespersons to
argue their case. Unfortunately their motion was
defeated.
http://www.parliament.scot/parliamentarybusiness/164
89.aspx
The families also took part in and Independent review led
by Professor Cairns Smith but felt that although they had
done the best job with the time and remit they had it
didn’t answer the families questions.
http://library.nhsggc.org.uk/media/215281/Independent
%20review.pdf
11. The families then lodged a petition to the Petitions
committee of the Scottish Parliament. The petition was
heard by the petitions committee and family members
also spoke to the members. For the very first time at an
actual petitions committee they made the decision to
support the
petitioners.http://archive.scottish.parliament.uk/s3/com
mittees/petitions/or-09/pu09-0202.htm
http://www.parliament.scot/parliamentarybusiness/Curr
entCommittees/40030.aspx
During this time the families also took part in the
Procurator Fiscals police investigation, asked freedom of
information questions, continued to lobby politicians and
even filmed a BBC Investigates programme.
In April 2009, the Cabinet Secretary for Health Nicola
Sturgeon announced that there would be a Public Inquiry
held into the deaths at the Vale of Leven hospital.
12. The Inquiry Begins.
On the 1st
October 2009 the inquiry was officially set up
and it had its first preliminary hearing on the 1st
February
2010.
The Chairman appointed to the inquiry was the Rt Hon
Lord Mclean. Lord Mclean then appointed Colin J
MacAulay QC as Senior Council and Lauren Sutherland,
Advocate as Junior Council to the inquiry. The Chairman
also appointed two specialist assessors to provide him
and Counsel with medical and nursing advice. They are
Dr Geoff Ridgway OBE and Mary Waddell OBE.
13. Oral hearings were heard over a 2 year period in Maryhill
Community Halls with a total of 126 days of evidence
having been given from witnesses.
Evidence was heard from families of those who lost their
lives, survivors , nurses , doctors, the health board and
expert testimonies.
There was also written evidence from those who couldn’t
give oral evidence.
The inquiry team sifted through piles of medical records
and other written evidence.
Warning letters were sent out to people or organisations
who would be named and critcised in the report. They
would then be allowed time to respond to the warning
letters and any critisism.
Once all this had been done Lord Mclean was then able
to write his report and publish his findings.
14. Did the families get their
answers ?
Finally, on the 24th
November 2014, 7 years after the
outbreak at the Royal College of Surgeons the report was
published and the families had their chance to see
whether the inquiry would answer the questions they
had about the loss of their loved ones.
http://www.valeoflevenhospitalinquiry.org/
15. The evidence heard during the inquiry was harrowing
and difficult to hear but the report validated the families
fight for answers and for lessons to be learned.
1
The report highlighted significant failings in patient care
including failure to fill in medical notes and charts, the
use of antibiotics when not needed, misdiagnosing of
infections and no on site infection control team.
The families believed they had the answers they so
desperately needed to why they had lost their loved ones
and also they had been right to fight for a public inquiry.
16. In total the report put forward 75 recommendations and
the Health Secretary Shona Robison accepted all the
recommendations.
She then set up an implementation group who's job
would be to oversee that they were put in place and all
Health Boards had to report to the group on how they
were doing it and whether it was sustainable.
Members of the C-Diff justice group have a place on the
implementation group and have been able to ensure that
the lessons from the inquiry are being learned.
The Implementation Group is chaired by Professor Fiona
McQueen, Chief Nursing Officer in Scotland.
17. It is also made up of other people from the medical
profession who are able to ensure that the
recommendations are implemented in the best way for
the people who use our NHS.
http://www.gov.scot/Topics/Health/Services/Preventing-
Healthcare-
Infections/Valelevenhospitalinquiry/VOLHImplementatio
nReferenceGroups
The group will report directly to the Scottish Government
through the Chief Nursing Officer.
The group recently had family members represent them
at the Excellence in Care, Scotland's approach to
ensuring Nursing and Midwifery care launch.
http://www.gov.scot/Publications/2015/09/8281/0
The Families will continue until they know that no other
families will have to go through the heartbreak they have.
18. A word from those involved.
"My interest in the Vale of Leven C-Diff inquiry was due
to the passing of my mother. She was first admitted to
hospital in December 2007 due to her diabetic condition,
unfortunately during her time in the wards she
contracted severe diarrhoea for which doctors where
unable to find a cause nor a suitable treatment. Later she
was moved to another ward and within 24 hours she was
placed in isolation and I was informed she had
contracted C-Difficile. My mother came very close to
passing away over those few days, but she made a
limited recovery she later died on August 2008 aged 69
years old. I was aware at the time of my mothers passing
from the media of the declared outbreak of C-Difficile
and some time later I had contact with the local group,
who had all also within their own families lost a loved
one or had a family member affected by this dreadful
infection. The work of the group along with our local
MSP was instrumental in getting a public inquiry initiated
after the declaration from the Fiscals office there was no
criminal case to answer.
19. The public inquiry for me was a very interesting
procedure and having given my own witness statement
and listened to that of others, having left no stone
unturned. The final report from Lord McLean listed a
wide ranging list of issues failings to be addressed and
stated that a systemic from Government level down to
the nursing staff on the wards. The final report if adopted
and actioned by all health boards in Scotland and indeed
if lessons have been learnt by the medical professions
across the UK, will mean that the pain and suffering of
those affected and the loss of family members will not
have been in vain and the work of the C-Diff group and
my own very small part in that can have a positive
outcome for others in the future."
Gareth Bourhill
Son of Janet Fitzsimmons
20. "I received a phone call on the 3rd
December 2007 to
inform me that my mum had collapsed at home and had
been rushed to hospital with a stroke. After being
diagnosed she was moved to Ward F, the stroke
rehabilitation unit and would remain there, until she
ultimately passed away there. The decision to take her
home for her was made very quickly after her diagnosis
but we had to leave her in hospital for a total of 8 weeks
awaiting a care package being put in place. One week
before she died she caught C-Difficile and that will be a
week our family will never forget, we will never forget
her pain and suffering or the loss of dignity of this awful
infection. After she passed away on 1st
February 2008
aged just 67, the family tried to move on and continue
with our lives but we still questioned what had happened
to our mum. 4 months later the outbreak came to light
through the local media and we came forward and
became part of the C-Diff Justice Group. We campaigned
for 2 and a half years for a public inquiry to get those
answers as to why our loved ones had lost their lives. We
took part in the Inquiry all the family giving witness
statements and others giving oral evidence.
21. The inquiry took a long time but it didn’t shirk its duties.
Listening to the evidence being given by family members
was hard but the evidence from medical staff was
heartbreaking. I believe the inquiry brought me the
answers I needed to understand what happened to my
mum, it will never bring her back but the lessons learned
may save the lives of others and that means at least she
didn’t die in vain."
Ann McGinty
Daughter of Sarah McGinty
"The families in the C-Diff justice group came together to
demand answers from the Greater Glasgow and Clyde
health board and the Scottish Government about what
happened to their loved ones at the Vale ofLeven. When
so many people were affected and the mortality rate was
so shockingly high, it was important to learn the lessons
so that this didn’t happen again. Whilst this was a
personal tragedy for each of the individual families
involved , it was also a national scandal that needed
addressed.
22. The best way to do that, in my experience, is to have a
judge led public inquiry, with the ability to command
attendance of witnesses, with evidence taken under oath,
and with clear recommendations that are mandatory. If
the families had not persevered, we might not know the
full story that lay behind the tragedy that occurred at the
Vale of Leven Hospital, and Scotland would not have
learned important lessons about the prevention of
hospital acquired infections."
Jackie Baillie MSP
23. "There have only been 4 public inquiries in Scotland since
the Inquiries Act 2005 was enacted. I have been heavily
involved in 3 of those Inquiries.
There is a very strong argument that the Vale of Leven
Hospital Inquiry was both the hardest fought Inquiry to
achieve and the most successful in terms of outcome for
the victims.
The Stockline Inquiry was a cross border Inquiry. A strong
trade union lobby had a significant influence on a Labour
Government in Westminster in terms of the that inquiry
being set up. Setting up the Contaminated Blood
(Penrose)inquiry was a very early announcement of the
first SNP Government. It was a political decision to keep
a pre-election promise; Nicole Sturgeon, john Swinney
and others having personally thrown their weight behind
the calls for an inquiry whilst in opposition.
In contrast the campaign for an inquiry in relation to the
Vale of Leven was a local campaign, spearheaded by local
victims with the support of their local MSP who, crucially,
was a well known member of the Shadow Cabinet. The
fight for a Public Inquiry was going to be extremely
difficult.
24. And yet the victims succeeded because of their clear,
unswerving, dignified and compelling case that they
made to the parliament and the public through the
media interest, parliamentary questions and engagement.
I'd like to think I played my part in that strategy. I advised
on setting up a campaign group to help catch the public
interest and in order that the whole would be far bigger
and more powerful than its constituent parts. I was also
involved throughout the campaign.
The C-Diff Justice Group engaged to the highest level
with the press and politicians. The launch of the group
was particularly moving and powerful with the use of
images of victims and the fact that individual members of
the group were able to talk with such eloquence and
power about their goals.
It was a long battle. The groups commitment to their goal
was unquestionable. There were many political meetings
where it seemed as if the Government wouldn’t move.
The Health Minister made changes and even
commissioned an "expert report" in the hope it would
salve the victims demands. But it didn’t because it wasn’t
enough and the fight continued.
25. At each stage the Group, the individual spokespeople,
Jackie Baillie and I were able to clearly articulate in a way
the public understood that only an independent, forensic
and judicial led inquiry would suffice.
The argument was won in the court of public opinion and
finally an Inquiry was set up under the chairmanship of
Lord McLean.
Was it worth it? In short, yes. Particularly in comparison
to the other inquiries under the 2005 act.
There were delays and that caused significant upset. But
evidence( that was extremely difficult for families) came
to light that simply otherwise would not have. In contrast
to Stockline and Penrose the report was damning. It
pulled no punches and laid bare the root and branch
failures that went all the way to the top of the health
board. I would say there was a sense of palpable anger in
some sections of Lord McLean's report. The report, and
the indictment of the NHS, stands in stark contrast to the
minor changes previously made by the Health Minister
and the fairly anodyne 'expert report'.
26. Lord McLean made 75 recommendations and the
Scottish Government accepted them all. The NHS in
Scotland will be better because of the Vale of Leven
hospital Inquiry. That, in turn, is entirely down to the
organisation, tenacity and dignity of the victims.
Patrick McGuire
Thompsons Solicitors
27. Conclusion
So in conclusion , although the fight was long and hard
the families believe that a public inquiry was the right
way to get the answers as to why they lost their loved
ones.
Although the public inquiry was harrowing and traumatic
to listen to at times the families believed it did a
thorough job leaving no stone unturned.
The families wanted to make sure that not only did they
get the answers to their loved ones deaths they also
wanted to do whatever they could to ensure no other
family went through their heartache.
Between January 2007 and December 2008 143 patients
in the Vale of Leve Hospital tested positive for C-Difficile,
34 of them died, although that number could be higher
as some medical records were not available.
They had failings in their care. The victims and their
families had been badly let down by those who they
trusted at their most vulnerable. There was systemic
failures all the way to the top.
28. The families have fought for 7 years to ensure that the
lessons to ensure this tragedy can never be
repeated.Their loved ones will never be forgotten and
work is under way on a forever reminder of those lost.
29. Timeline
Dec 2007 – First patients die from C.Diff at Vale of Leven hospital
June 2008 – A total of 18 patients have died since the outbreak
June 18, 2008 – Nicola Sturgeon, then Health Minister, announces an independent review of the cases
of clostridium difficile-associated disease
August 7, 2008 – Findings and recommendations of independent review published. More than 20
failings discovered
October 1, 2009 – Inquiry announced into the deaths, gathering and assessing of evidence begins
February 1, 2010 – The preliminary hearing of the inquiry chaired by Lord MacLean begins with
instruction to report by May 31, 2013
January 2012 – Infectious diseases expert Professor George Griffin tells the inquiry 10 more deaths at
the hospital were attributable to C.Diff
February 9, 2012 – Labour MSP for Dumbarton Jackie Baillie points out that there were actually 38
deaths at the Vale of Leven hospital
February 23, 2012 – Sturgeon says the inquiry is looking at the treatment of 60 patients – including 38
deaths – although she insists that this does not mean the inquiry has accepted that the C.Diff outbreak
caused all 38 deaths
June 26, 2012 – Oral hearings end. In total, there were 126 days of oral evidence
October 28, 2012 – First warning letters issued. These are letters to any individual or organisation likely
to be the subject of significant or explicit criticism in the report
March 22, 2013 – Due to chairman’s illness, the date of the publication of the inquiry report is extended
to autumn 2013, then further extensions
November 24, 2014 – Report is finally published 18 months late and almost seven years after the first
deaths
