Staff at Glasgow hospital told ‘We don’t put things in writing’, inquiry hears

A microbiology specialist who worked at a Glasgow hospital at the centre of infection concerns has told an inquiry that known problems in a children’s bone marrow transplant ward were not addressed for years because of a “lack of a joined up approach” by hospital management.

Dr Christine Peters, who started work as a consultant microbiologist at Queen Elizabeth University Hospital in 2014, told the Scottish Hospitals Inquiry that by June 2015, just months after the new facility opened, she had a number of serious concerns about patient safety resulting from the way the hospital had been designed, built and signed off.

These included issues with the air ventilation system, problems with the design of sinks, and facilities intended for highly infectious patients lacking key infection control measures, such as appropriate air pressures.

However, the infection control specialist described how she struggled with a dysfunctional management culture that she said made it practically impossible to get detailed information about the design or testing of the water and air ventilation systems, or clarity about how to escalate her concerns once she had them.

She said that she first became aware of issues at the hospital during walk-rounds of the new facility while it was still a “building site” in October 2014, when she saw “greenish puddles” around sink drains.

Dr Peters also noticed that a room she expected to have been a negative air pressure room – a key feature for infection control – was not what she expected, and that, when she queried it, she was told that it had been signed off by a senior member of staff.

She told the inquiry she tried to get technical information about the air ventilation system “to enable me to do my job” in controlling infection risks, but that managers ignored her requests.

In a further walk-around in June 2015, after patients had moved in, she described finding the room that was designated for patients with “viral haemorrhagic fever”, such as Ebola, to be unfit for purpose due to the absence of some infection control facilities.

The room also had some basic defects, such as a missing ceiling tile, the fact the automatic doors kept opening and closing, and “the flooring material wasn’t suitable for the level of cleaning that would be required”.

She also had specific concerns about wards 4B and 2A, where very vulnerable patients were undergoing bone marrow transplants, and where air quality should have been very strictly controlled.

She described doing air quality testing in 4B in late June 2015, and finding that rather than being “less than one”, the number of particles in the air was “in the millions. It wasn’t just a little bit off, it was just wildly off.

“Lots of fungus on all the (testing) plates, and huge counts in some of the rooms, massive counts, as big as outdoor counts.”

However, she added that given what she had seen about the inadequate ventilation in the ward, “you’d say that’s not surprising”.

The inquiry heard that while action was taken to address the problems in 4B very soon after these findings were made, the issues in ward 2A, where children were receiving bone marrow transplants, were not addressed until “well into 2018 or thereabouts”.

The inquiry chair, Lord Brodie, asked Dr Peters why this was, and she replied: “I think it speaks to a lack of a joined up approach, where we really needed to say, ‘let’s start again from scratch, We don’t actually know what we have. And take it from there.’

“Things seem to happen in pockets of activity across the organisation that I wasn’t privy to.

“From my limited visibility, I raised things, got involved, and then (was) blocked out, and there’s no further information. And you’re then in the position where you’re hoping something’s happening, but not in the sure knowledge that something’s happening.”

She also told the inquiry that she had been “very shocked” to be told by a senior manager in 2014, soon after she joined the hospital, not to raise concerns in writing in case there was an inquiry.

She said that after an infection issue in the old Southern General hospital building she had written an email setting out lessons learned, only to receive a phone call from a senior colleague telling her: “You’re in Glasgow now. We don’t put things in writing because of inquiries and things.

“I remember the words, and I was pretty shocked.”

Lord Brodie pressed her if she was “clear” that he had said this, and she replied: “Very clear indeed.”

The inquiry is currently investigating the construction of the QEUH campus in Glasgow, which includes the Royal Hospital for Children.

The inquiry was launched in the wake of deaths linked to infections, including that of 10-year-old Milly Main.

The inquiry continues.

An NHS Greater Glasgow and Clyde (NHSGGC) spokesman said: “These matters are to be explored in the ongoing inquiry and while NHSGGC continues to co-operate with the Inquiry, it would be inappropriate to comment on this at this time.”