QUEH infection daiths – whaur’s the regulator?

The primary legal duty fir safety faws oan NHS Scotland, but there is aye-an-oan a legal duty oan the regulator. But whaur are they in this bourach?

The muckle Englis scandal that brocht patient safety intae the news wis the Mid Staffordshire NHS Trust debacle.

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Some o ye’se micht hae seen the tither week the braw haurd-hittin TV drama The Cure oan Channel 4 anent the Mid Staffs disaster. The public inquiry intae this, rin bi Sir Robert Francis, fand mony cases o puir care wi a byordnar nummer o daiths melded wi puir regulation. Fir us bidin in Scotland there is nae independent information oan safety or the nummer o daiths, it is aa controlled bi the NHS. There is nae reliable wey o kennin hou guid or bad oor healthcare is. NHS Scotland merks its ain hamewark – an naebody e’er checks it.

Ae major factor in Mid-Staffs wis the puir regulation, a “regulatory gap”; but we in Scotland hae a “regulatory vacuum”. Naebody hus bin regulatin patient safety. That in itsel is heichly unlawfu. Health care hus the biggest risks an requires the best regulation; yet we get nane.

The legal responsibility fir makkin siccar law is complied wi bides wi the Health and Safety Executive (HSE). Wi the muckle nummer o staff an heich risks tae patients HSE uised tae gie a loat o attention tae the inspections o hospitals an ither pairts o the healthcare system.

Yet in 2012 HSE signed an agreement wi NHS Scotland tae no regulate patient safety. This agreement wis anely reversed this year eftir years o pressure frae fowk lik masel an ma fellae campaigners in Action fir a Safe and Accountable People’s NHS (ASAP-NHS).

Fir seeven lang years naebody wis regulatin patient safety in Scotland. Naebody wis ensurin oor safety. Oh aye, we hud bodies o "scrutiny and assurance" lik HIS, but nae regulator. Cuid ye imagine that heppenin in the Nuclear, Railways or North Sea Oil industries?

The verra best estimates propone that the failures tae comply wi the patient safety law wull mean about 2000 raisonably preventable daiths a year. HSE aiblins meets the criteria fir bein prosecuted itsel. Puir regulation leads tae mony daiths; the Piper Alpha disaster wis ane, the Grenfell Touer fire wis anither ... In wir NHS the daiths fir ordinar heppen ane at a time, it is anely when they heppen mair as ane at a time that they can get noticed. This is aye-an-oan a disaster – but ane that hides itsel frae public view.

The QEUH hospital kythes hou the failure o HSE tae regulate plays a pairt in the infections an daiths. The law oan patient safety hus applied syne 1974 yet HSE hae duin gey little tae see that that law wis follaed. We at ASAP-NHS hae fand NHS Scotland tae no e’en hae kent that the law applied – and HSE kept quate aboot it. Whilst in rUK, HSE prosecuted oan it! Sae, guid people, when it cam tae designin QEUH and the new children’s hospital thair wis nae appairent unnerstaunin o the law an hou it applied tae the design tae prevent infections, else hou cuid these daiths hae heppent?

Designs shuid ettle tae eliminate risk – an whaur that cannae be duin precautions maun wark. The evidence pynts tae thair bein a contaminated watter risk richt frae the stairt. HSE seems no tae hae checked the hospital.

Compare that wi the strict approach tae design an regulation o a nuclear pouer station – while the risk factor in hospital design is in fact vastly greater.

Ma belief is that HSE ne’er cairriet oot an inspection tae mak siccar that the QEUH complied wi the law oan infection control – lat thaim say itherwise. Fir the entire lifetime o the hospital it hus gane unregulated, it hus operated ootside the law. Unbelievable, ah ken.

HSE is bound bi law tae check precautions – no wait till hairm occurs. It wis 25 year ago that HSE stairtit tae ensure that the law oan infection control (Coshh) wis complied wi fir patients. HSE appear tae hae forgotten this. Back in thae days HSE identified infection as “a major incident”. In Novemeber 2018 HSE respondit tae tae a complaint bi staff oan twa wards oan the infection risk. It fand major failins and issued legal notices requirin impruivements.

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It wis bad enow tae meet the criteria fir HSE tae stairt the prosecution procedure. It didnae dae this – why no?. It alsae failed tae inspect oan patient safety. Gin it hud then it wid hae seen that the law wis ignored. It is aamaist certain that gin it hud then lives cuid hae bin saved.

A year later, an the problems an the infection daiths are conteenuin. At last a public inquiry hus bin cried fir bi oor health meenister Jeane Freeman. A verra able wumman, wha’ll no hae the wool pu’d ower her een! But we cannae wait years fir the outcome o an inquiry – we need tae ken whit is bein duin this verra meenit tae tae mak siccar that this hospital, and ithers, are safe richt nou! ASAP-NHS pyntit oot tae HSE that the situation at QEUH met HSE’s ain definition fir declarin a major incident.

HSE’s new CEO Sarah Albon refused tae follae her ain procedures; we hae this in writing. HSE, keep mind, is the anely independent body that can gae in and thoroughly inspect. HSE hus form – loats ae bad form. It refused tae tak pairt in the previous public inquiries intae infection daiths.

These wir the Vale of Leven hospital inquiry (30 – 50 infection daiths) and the Penrose Inquiry intae contaminated bluid daiths (~200 daiths in Scotland, aiblins 2000 in the UK).

Fae the Vale of Leven it meant that the law wis totally missin – an tae this day infection daiths conteenue, unchecked bi the law that is meant tae protect us aa, athort the hale o NHS Scotland.