Vale of Leven Hospital Inquiry
CompletedVale of Leven Inquiry
The Vale of Leven Hospital Inquiry investigated the occurrence of Clostridium difficile infection at the Vale of Leven Hospital from 1 January 2007 onwards, particularly between 1 December 2007 and 1 June 2008, and the deaths associated with that infection. The inquiry identified 34 deaths where C. difficile infection was implicated and found serious deficiencies in infection control practices. The report made 75 recommendations on infection prevention and control, leadership, and patient safety.
5 years, 3 months
Duration
Parliamentary Activity 5 Click to expand
since Jun 2016
05 Sep 2023
Early Day Motion
Red Ramp Events and the Golden Friendship Club
Martin Docherty-Hughes (Scottish National Party)
18 Apr 2023
Martin Docherty-Hughes (Scottish National Party)
Early Day Motion
50 years of West Dunbartonshire Citizens Advice Bureau
Martin Docherty-Hughes (Scottish National Party)
08 Sep 2021
Martin Docherty-Hughes (Scottish National Party)
Early Day Motion
20TH ANNIVERSARY OF THE MURDER OF CAROLINE GLACHAN
Martin Docherty-Hughes (Scottish National Party)
05 Sep 2016
Martin Docherty-Hughes (Scottish National Party)
Early Day Motion
QUEEN'S AWARD FOR VOLUNTARY SERVICE TO THE VALE OF LEVEN AUTISM AND …
Martin Docherty-Hughes (Scottish National Party)
15 Jun 2016
Martin Docherty-Hughes (Scottish National Party)
Reports (1) Click to expand
| Title | Volume | Publication Date | Recs | Links |
|---|---|---|---|---|
| The Vale of Leven Hospital Inquiry Report | Final Report | 24 Nov 2014 | 75 |
Timeline (3) Click to expand
01 May 2009
Inquiry Announced
01 Nov 2009
Inquiry Established
24 Nov 2014
Final Report Published
Recommendations (75)
HEI ward closure powers
Recommendation
Scottish Government should ensure that the Healthcare Environment Inspectorate (HEI) has the power to close a ward to new admissions if the HEI concludes that there is a real risk to the safety of patients.
Published evidence summary
According to Healthcare Improvement Scotland in January 2024, the Healthcare Environment Inspectorate (HEI) has possessed the power to close wards to new admissions when patient safety is at risk since April 2009. According to the NHS (Scotland) Act 1978, this power was established under statutory provisions; furthermore, according to the available evidence, HEI has conducted over 200 inspections since its inception, including unannounced visits.
Scottish Government
(Primary)
View Details
HAI implementation strategy
Recommendation
Scottish Government should ensure that policies and guidance on healthcare associated infection are accompanied by an implementation strategy and that implementation is monitored.
Published evidence summary
According to the Scottish Government, successive strategies for healthcare associated infection (HAI) have been implemented and monitored, including the AMR/HAI 5-Year Strategic Framework 2016-2021 and the HCAI Strategy 2023-2025. According to a March 2025 progress report, all 30 first-phase deliverables of the HCAI Strategy had been progressed by June 2024, with six completed, and a new five-year IPC strategy for 2025-2030 is in development, with the National Infection Prevention and Control Manual (NIPCM) and Care Home IPCM established and operational, with performance monitored through HEI inspections.
Scottish Government
(Primary)
View Details
IPC policy review
Recommendation
Health Boards should ensure that infection prevention and control policies are reviewed promptly in response to any new policies or guidance issued by or on behalf of the Scottish Government.
Published evidence summary
According to the Scottish Government, this recommendation was accepted, requiring NHS boards to adhere to revised Healthcare Associated Infection (HAI) Standards and the National Infection Prevention and Control Manual (NIPCM). According to the Chief Nursing Officer on 11 July 2022, the NIPCM was relaunched, providing continuously updated evidence-based guidance for all NHS Scotland, and was further updated in 2023.
NHS Health Boards (Scotland)
(Primary)
View Details
Local HAI Task Forces
Recommendation
Scottish Government should develop local healthcare Associated infection (HAI) Task Forces within each Health Board area.
Published evidence summary
The Scottish Government accepted this recommendation in 2015. The national Healthcare Associated Infection (HAI) Taskforce was restructured to work with local teams and existing NHS board structures. The Scottish Government developed the AMR/HAI 5-Year Strategic Framework 2016-2021, which included local implementation structures, and this was succeeded by the HCAI Strategy 2023-2025 with established local governance arrangements (Scottish Government, 2016-10-18).
Scottish Government
(Primary)
View Details
Hospital future uncertainty resolution
Recommendation
Scottish Government should ensure that where any uncertainty over the future of any hospital or service exists, resolution of the uncertainty is not delayed any longer than is essential.
Published evidence summary
According to the Scottish Government (2015-06-18), this recommendation was accepted in 2015, with a commitment to ensure resolution of uncertainty over hospital futures is not delayed. However, according to the available evidence, no specific legislative or structural reform was introduced to prevent this issue recurring, with the government's response outlining broader health policy initiatives rather than concrete mechanisms for resolving specific hospital uncertainties without delay; furthermore, according to the available evidence, no further published evidence has been identified since 2015.
Scottish Government
(Primary)
View Details
Service change continuity plans
Recommendation
Scottish Government should ensure that where major changes in patient services are planned there should be clear and effective plans in place for continuity of safe patient care.
Published evidence summary
According to the Scottish Government's response (2015-06-18), it committed to ensuring clear plans for continuity of safe patient care during major service changes. According to the Scottish Government (2016), the National Clinical Strategy for Scotland (2016) and subsequent workforce planning frameworks address service change management. According to the available evidence, no further specific enforcement mechanisms or recent updates on these plans have been identified since 2016.
Scottish Government
(Primary)
View Details
Reorganisation due diligence
Recommendation
In any major structural reorganisation in the NHS in Scotland a due diligence process including risk assessment, should be undertaken by the Board or Boards responsible.
Published evidence summary
According to the Scottish Government response, 18 June 2015, the Scottish Government's response indicated that due diligence requirements for NHS reorganisations are addressed through existing governance frameworks, including the 'Governance for Quality Healthcare in Scotland - an Agreement' and the Code of Corporate Governance for NHS Scotland. According to the available evidence, these frameworks provide an overarching structure for NHS board governance. No further specific legislative or policy changes mandating a new due diligence process for major structural reorganisations have been publicly identified since 2015.
NHS Health Boards (Scotland)
(Primary)
View Details
Reorganisation management structure
Recommendation
In any major structural reorganisation in the NHS in Scotland the Board or Boards responsible should ensure that an effective and stable management structure is in place.
Published evidence summary
According to the Scottish Government response (18 June 2015), the Scottish Government's response committed to ensuring effective management structures during reorganisations, stating that this is addressed through existing governance frameworks and investment in leadership and management development. NHS boards are expected to build local leadership and management capacity as part of their workforce plans. According to the available evidence, no further specific legislative or policy changes directly mandating a new process for ensuring stable management structures during major reorganisations have been publicly identified since 2015.
NHS Health Boards (Scotland)
(Primary)
View Details
IPC clinical governance meetings
Recommendation
Health Boards should ensure that infection prevention and control is explicitly considered at all clinical governance committee meetings from local level to Board level.
Published evidence summary
According to the Scottish Government response (18 June 2015), the Scottish Government's response stated that infection control managers are integral members of clinical governance committees and that NHS boards must have infection-control committee structures. According to Healthcare Improvement Scotland's (HIS) IPC Standards (2022) (Healthcare Improvement Scotland, 1 May 2022), Standard 1 (Leadership and Governance) explicitly requires infection prevention and control to be considered at all clinical governance levels, from ward to Board. According to the Scottish Government Oversight Board (1 March 2021), the Queen Elizabeth University Hospital (QEUH) Oversight Board found in March 2021 significant failings in governance and a reactive response to IPC issues within NHS Greater Glasgow and Clyde, indicating a failure in practical application of these standards.
NHS Health Boards (Scotland)
(Primary)
View Details
CDI patient information
Recommendation
Health Boards should ensure that patients diagnosed with CDI are given information by medical and nursing staff about their condition and prognosis.
Published evidence summary
According to the revised Charter of Patient Rights and Responsibilities (June 2022) under the Patient Rights (Scotland) Act 2011, NHS Health Boards are required to provide patients diagnosed with *C. difficile* infection (CDI) with information about their condition and prognosis. According to the Health (Tobacco Nicotine etc. and Care) (Scotland) Act 2016 and its 2018 Regulations, the statutory Duty of Candour further mandates organisations to inform patients about incidents; furthermore, according to the available evidence, non-statutory guidance for this duty was revised in March 2025.
NHS Health Boards (Scotland)
(Primary)
View Details
CDI severity awareness
Recommendation
Health Boards should ensure that patients, and relatives where appropriate, are made aware that CDI is a condition that can be life-threatening, particularly in the elderly.
Published evidence summary
According to the revised Charter of Patient Rights (June 2022), NHS Health Boards are mandated to ensure patients and their relatives are made aware of the life-threatening nature of *C. difficile* infection (CDI), particularly for the elderly. According to the statutory Duty of Candour, this is supported, which requires organisations to inform affected persons about conditions and associated risks; furthermore, according to The Duty of Candour Procedure (Scotland) Regulations 2018, the process is outlined for providing information and apologies following safety incidents.
NHS Health Boards (Scotland)
(Primary)
View Details
CDI infection control advice
Recommendation
Health Boards should ensure that when a patient has CDI patients and relatives are given clear and proper advice on the necessary infection control precautions.
Published evidence summary
According to the Duty of Candour and the revised Patient Rights Charter (June 2022), NHS Health Boards are required to provide clear and proper advice on infection control precautions to patients with *C. difficile* infection (CDI) and their relatives, which strengthens communication requirements. According to Healthcare Improvement Scotland's Infection Prevention and Control (IPC) Standards (2022), Standard 3 mandates effective communication about IPC with patients and families across all health and social care settings, which reinforces this requirement.
NHS Health Boards (Scotland)
(Primary)
View Details
Clear nursing responsibility line
Recommendation
Health Boards should ensure that there is a clear and effective line of professional responsibility between the ward and the Board.
Published evidence summary
According to the Scottish Government, the Excellence in Care (EiC) framework was commissioned and is operational in every NHS board with dedicated leads and a 2022-2025 strategy, to enhance nursing leadership and professional responsibility from the ward to the Board, and the CAIR Dashboard also provides nursing and midwifery care quality metrics. According to a Scottish Government Oversight Board report from March 2021, there were 'significant failings in governance' at NHS Greater Glasgow and Clyde between 2015-2019, leading to its escalation within the NHS Scotland performance framework.
NHS Health Boards (Scotland)
(Primary)
View Details
Patient records compliance audit
Recommendation
Health Boards should ensure that the nurse in charge of each ward audits compliance with the duty to keep clear and contemporaneous patient records.
Published evidence summary
According to the Excellence in Care (EiC) framework, NHS Health Boards are supported in ensuring compliance with clear and contemporaneous patient records through the CAIR Dashboard. According to Healthcare Improvement Scotland in January 2025, this dashboard monitors nursing care quality metrics, specifically encompassing record-keeping standards across all NHS Scotland boards, and every board has dedicated EiC and Digital Leads to support this work.
NHS Health Boards (Scotland)
(Primary)
View Details
CDI patient observations records
Recommendation
Health Boards should ensure that nursing staff caring for a patient with CDI keep accurate records of patient observations including temperature, pulse, respiration.
Published evidence summary
According to the Excellence in Care (EiC) framework, NHS Health Boards ensure that nursing staff caring for patients with *C. difficile* infection (CDI) maintain accurate records of patient observations, including temperature, pulse, and respiration. According to Healthcare Improvement Scotland in January 2025, the CAIR Dashboard monitors compliance with these nursing documentation requirements across all NHS Scotland boards, incorporating patient observation recording standards, which establishes a national, standardised approach to patient record-keeping.
NHS Health Boards (Scotland)
(Primary)
View Details
CDI outbreak reporting
Recommendation
Health Boards should ensure that the nurse in charge of each ward reports suspected outbreaks of CDI (as defined in local guidance) to the Infection Control Team.
Published evidence summary
According to Healthcare Improvement Scotland's (HIS) Infection Prevention and Control (IPC) Standards (2022), NHS Health Boards are required to ensure that suspected outbreaks of *C. difficile* infection (CDI) are reported to the Infection Control Team, specifically Standard 4, and the National Infection Prevention and Control Manual (NIPCM) provides detailed outbreak management guidance, including mandatory CDI outbreak reporting protocols. According to Public Health Scotland, national mandatory CDI surveillance has been operational since 2006 for patients aged 65+ and since April 2009 for all patients aged 15+, with quarterly epidemiological data published.
NHS Health Boards (Scotland)
(Primary)
View Details
Ward admission responsibility
Recommendation
Health Boards should ensure that where there is risk of cross infection, the nurse in charge of a ward has ultimate responsibility for admission of patients to the ward or bay.
Published evidence summary
According to the Excellence in Care framework and the National Infection Prevention and Control Manual (NIPCM), NHS Health Boards address the responsibility of the nurse in charge for patient admissions during cross-infection risk. According to Healthcare Improvement Scotland's (HIS) Infection Prevention and Control (IPC) Standards, Standard 4 covers ward-level infection management and admission decisions. According to Healthcare Improvement Scotland in January 2025, operational compliance with these national standards varies across different NHS boards.
NHS Health Boards (Scotland)
(Primary)
View Details
Care planning system
Recommendation
Health Boards should ensure that there is an agreed system of care planning in use in every ward with the appropriate documentation available to nursing staff.
Published evidence summary
According to the Excellence in Care (EiC) framework, NHS Health Boards ensure an agreed system of care planning is in use in every ward with appropriate documentation for nursing staff, which was commissioned specifically in response to the Vale of Leven Inquiry, and directly addresses care planning systems. According to Healthcare Improvement Scotland in January 2025, the CAIR Dashboard monitors fundamentals of care, including care planning documentation, across all NHS Scotland boards.
NHS Health Boards (Scotland)
(Primary)
View Details
ICN instructions recorded
Recommendation
Health Boards should ensure that where Infection Control Nurses provide instructions on the management of patients those instructions are recorded in patient notes.
Published evidence summary
According to professional standards for record-keeping for nurses and doctors, NHS Health Boards are guided to ensure that instructions from Infection Control Nurses (ICN) on patient management are recorded in patient notes. According to the Excellence in Care (EiC) framework, nursing documentation standards, including the recording of ICN instructions, are monitored, and the CAIR Dashboard tracks care documentation compliance across all boards. According to Healthcare Improvement Scotland in January 2025, board-level compliance with these specific documentation standards varies.
NHS Health Boards (Scotland)
(Primary)
View Details
Stool records for CDI patients
Recommendation
Health Boards should ensure that where a patient has, or is suspected of having, C.difficile diarrhoea a proper record of the patient's stools is kept.
Published evidence summary
According to the National Infection Prevention and Control Manual (NIPCM), NHS Health Boards ensure that proper records of a patient's stools are kept when *C. difficile* diarrhoea is present or suspected, which includes specific guidance on *C. difficile* infection (CDI) patient management, encompassing stool monitoring. According to Healthcare Improvement Scotland in January 2025, the Excellence in Care framework monitors fundamentals of care documentation standards, with ward-level compliance tracked via the CAIR Dashboard and Healthcare Environment Inspectorate (HEI) inspections.
NHS Health Boards (Scotland)
(Primary)
View Details
Nursing staff for relatives
Recommendation
Health Boards should ensure that a member of nursing staff is available to deal with questions from relatives during visiting periods.
Published evidence summary
According to the statutory Duty of Candour (2018 Regulations) and the revised Patient Rights Charter (June 2022), NHS Health Boards are required to ensure nursing staff are available to address questions from relatives during visiting periods, which strengthens communication requirements with relatives. According to the Excellence in Care framework, developed in response to the Vale of Leven Inquiry, 'Communication' is one of its four foundational requirements, directly addressing patient and family engagement.
NHS Health Boards (Scotland)
(Primary)
View Details
Relative discussions recorded
Recommendation
Health Boards should ensure that any discussion between a member of nursing staff and a relative about a patient which is relevant to the patient's continuing care is recorded.
Published evidence summary
According to the revised Nursing and Midwifery Council (NMC) code, effective March 2015, NHS Health Boards ensure that discussions between nursing staff and relatives relevant to a patient's continuing care are recorded, which mandates clear and accurate record-keeping. According to the statutory Duty of Candour (2018 Regulations), documentation of communications with patients and families regarding safety incidents is required, and the Excellence in Care framework's CAIR Dashboard monitors communication standards, including documentation of these discussions.
NHS Health Boards (Scotland)
(Primary)
View Details
TVN training and qualification
Recommendation
Health Boards should ensure that a nurse appointed as Tissue Viability Nurse (TVN) is appropriately trained and possesses, or is working towards, a recognised specialist post-registration qualification.
Published evidence summary
According to the Scottish Government, this recommendation was accepted, noting that accredited education programmes for specialist roles, including Tissue Viability Nurses (TVNs), are available through universities and funded by NHS boards, supported by a £1 million investment in 2012 for postgraduate education. According to Healthcare Improvement Scotland's Excellence in Care framework, nursing specialist training is covered, and according to NHS Education for Scotland (NES), specialist training pathways are provided via Turas Learn, though no specific national TVN qualification requirement has been mandated; furthermore, according to the available evidence, no further published evidence has been identified since 2025.
NHS Health Boards (Scotland)
(Primary)
View Details
TVN instructions recorded
Recommendation
Health Boards should ensure that where a TVN is involved in caring for a patient there is a clear record in the patient notes and care plan of the instructions given.
Published evidence summary
According to the Scottish Government, this recommendation was accepted, stating that professional standards for record-keeping, including the revised NMC code and GMC requirements, mandate clear, accurate, and timely documentation of patient care. According to Healthcare Improvement Scotland's Excellence in Care framework, care documentation is monitored, including specialist nursing instructions, with compliance tracked via the CAIR Dashboard; furthermore, according to the available evidence, no further published evidence has been identified since 2025.
NHS Health Boards (Scotland)
(Primary)
View Details
Pressure damage risk assessment
Recommendation
Health Boards should ensure that every patient is assessed for risk of pressure damage on admission to hospital using a recognised tool such as the Waterlow Score.
Published evidence summary
According to the Scottish Government, this recommendation was accepted, noting that pressure ulcer prevention and management is a fundamental aspect of nursing practice, supported by Healthcare Improvement Scotland's 2009 Best Practice Statement and the national Tissue Viability Programme. According to the Excellence in Care framework, pressure damage risk assessment is included as a fundamental of care, with the CAIR Dashboard monitoring compliance with prevention measures across all NHS boards; furthermore, according to the available evidence, no further published evidence has been identified since 2025.
NHS Health Boards (Scotland)
(Primary)
View Details
Wound documentation
Recommendation
Health Boards should ensure that where a patient has a wound or pressure damage there is clear documentation of the nature of the wound or damage in accordance with best practice guidance.
Published evidence summary
According to the Scottish Government, this recommendation was accepted, citing professional standards for record-keeping, including the revised NMC code and GMC requirements, which mandate clear and accurate documentation. According to Healthcare Improvement Scotland's Excellence in Care CAIR Dashboard, wound documentation standards are monitored as part of fundamentals of care metrics, and national wound care guidance is available; furthermore, according to the available evidence, no further published evidence has been identified since 2025.
NHS Health Boards (Scotland)
(Primary)
View Details
Positional change records
Recommendation
Health Boards should ensure that where a patient requires positional changes nursing staff clearly record this on a turning chart or equivalent.
Published evidence summary
According to the Scottish Government, this recommendation was accepted, referencing professional standards for record-keeping, particularly the revised NMC code, which mandates clear, accurate, and timely documentation of care, including positional changes. According to Healthcare Improvement Scotland's Excellence in Care framework, nursing documentation is monitored, including positional change records, with compliance tracked via the CAIR Dashboard; furthermore, according to the available evidence, no further published evidence has been identified since 2025.
NHS Health Boards (Scotland)
(Primary)
View Details
Nutritional screening
Recommendation
Health Boards should ensure that all patients have their nutritional status screened on admission to a ward using a recognised nutritional screening tool.
Published evidence summary
According to the Scottish Government, this recommendation was accepted, acknowledging past issues with nutritional status assessment and recording. According to Healthcare Improvement Scotland (HIS), National Food Fluid and Nutritional Care Standards have been published, and according to the Excellence in Care CAIR Dashboard, nutritional screening measures are now included, monitoring compliance across all NHS Scotland boards; furthermore, according to the available evidence, no further published evidence has been identified since 2025.
NHS Health Boards (Scotland)
(Primary)
View Details
Patient weighing equipment
Recommendation
Health Boards should ensure that there is appropriate equipment in each ward to weigh all patients. Patients should be weighed on admission and at least weekly thereafter.
Published evidence summary
According to the Scottish Government, this recommendation was accepted, detailing significant investment in NHS estates and equipment, including increased funding for NHS boards for equipment replacement. According to Healthcare Improvement Scotland's Excellence in Care framework, nutritional standards are included that require patient weighing on admission, with the CAIR Dashboard monitoring weighing compliance across all NHS boards; furthermore, according to the available evidence, no further published evidence has been identified since 2025.
NHS Health Boards (Scotland)
(Primary)
View Details
Fluid balance monitoring
Recommendation
Health Boards should ensure that where patients require fluid monitoring as part of their critical care, nursing staff complete fluid balance charts as accurately as possible.
Published evidence summary
According to the Scottish Government, this recommendation was accepted, referencing professional standards for record-keeping, particularly the revised NMC code, which mandates clear, accurate, and timely documentation of critical care elements such as fluid balance. According to Healthcare Improvement Scotland's Excellence in Care CAIR Dashboard, fluid balance chart completion is monitored as part of fundamentals of care metrics across all NHS Scotland boards; furthermore, according to the available evidence, no further published evidence has been identified since 2025.
NHS Health Boards (Scotland)
(Primary)
View Details
Staffing and skills mix review
Recommendation
Health Boards should ensure that the staffing and skills mix is appropriate for each ward, and that it is reviewed in response to increases in the level of activity/patient acuity.
Published evidence summary
According to the Scottish Government, this recommendation was accepted and mandatory nursing and midwifery workload and workforce planning tools were developed for all NHS boards. According to the Health and Care (Staffing) (Scotland) Act 2019, which came into force on 1 April 2024, a statutory basis is provided for appropriate staffing, including the Common Staffing Method with mandatory staffing level tools for adult inpatient wards, going beyond the inquiry's original recommendation.
NHS Health Boards (Scotland)
(Primary)
View Details
Staffing concerns escalation
Recommendation
Health Boards should ensure that there is straightforward and timely escalation process for nurses to report concerns about staffing numbers/skill mix.
Published evidence summary
According to the Scottish Government, this recommendation was accepted, noting the NMC code's requirement for nurses to escalate concerns and the existence of a national whistleblowing policy and a confidential alert line. According to the Health and Care (Staffing) (Scotland) Act 2019, which came into force in April 2024, statutory requirements are included for escalation processes when staffing levels fall below safe levels.
NHS Health Boards (Scotland)
(Primary)
View Details
Nursing complaint investigation
Recommendation
Health Boards should ensure that where a complaint is made about nursing practice on a ward this complaint is investigated by an independent senior member of Nursing Management.
Published evidence summary
According to the Scottish Government, this recommendation was accepted, acknowledging past issues with complaint management. According to the available evidence, while the NHS Scotland Complaints Handling Procedure was revised and standardised across all health boards, the specific requirement for complaints about nursing practice to be investigated by an independent senior member of Nursing Management was addressed through general complaints reform rather than a dedicated mechanism; furthermore, according to the available evidence, no further published evidence has been identified since 2015.
NHS Health Boards (Scotland)
(Primary)
View Details
Antimicrobial guidance implementation
Recommendation
Health Boards should ensure that changes in policy and/or guidance on antimicrobial practice issued by or on behalf of Scottish Government are implemented without delay.
Published evidence summary
According to the Scottish Government, this recommendation was accepted, establishing the Controlling Antimicrobial Resistance in Scotland Group and the Scottish Antimicrobial Prescribing Group (SAPG) to oversee and provide comprehensive guidance on antimicrobial stewardship. According to SAPG, operational since 2008, specific C. difficile-related prescribing guidance is published and prescribing data is monitored, reporting demonstrable year-on-year reductions in inappropriate prescribing; furthermore, according to the available evidence, no further published evidence has been identified since 2025.
NHS Health Boards (Scotland)
(Primary)
View Details
Antibiotic prescribing monitoring
Recommendation
Scottish Government should monitor the implementation of policies and/or guidance on antibiotic prescribing issued in connection with healthcare associated infection.
Published evidence summary
According to the Scottish Government, this recommendation was accepted, establishing the Controlling Antimicrobial Resistance in Scotland Group and the Scottish Antimicrobial Prescribing Group (SAPG) to monitor antibiotic prescribing policies nationally. According to SAPG, which celebrated 15 years of operation in 2023, prescribing data is published through Public Health Scotland and significant reductions in primary care antibiotic prescriptions and C. difficile risk-increasing antibiotics were reported by 2015; furthermore, antimicrobial stewardship is also integrated into Healthcare Improvement Scotland's IPC Standards 2022 and no further published evidence has been identified since 2025.
Scottish Government
(Primary)
View Details
Medical staffing levels
Recommendation
Health Boards should ensure that the level of medical staffing planned and provided is sufficient to provide safe high-quality care.
Published evidence summary
According to the Scottish Government, this recommendation was accepted, committing to planning an NHS workforce with structures and guidance for effective workforce planning. According to the Health and Care (Staffing) (Scotland) Act 2019, which came into force on 1 April 2024, a statutory basis is provided for ensuring medical staffing levels are sufficient for safe, high-quality care, applying the Common Staffing Method to all clinical staffing decisions.
NHS Health Boards (Scotland)
(Primary)
View Details
CDI senior assessment and treatment
Recommendation
Health Boards should ensure that any patient with suspected CDI receives full clinical assessment by senior medical staff, that specific antibiotic therapy for CDI is commenced timeously.
Published evidence summary
The Scottish Government accepted this recommendation in 2015. Detailed clinical guidance on Clostridioides difficile infection (CDI) assessment and treatment, including the requirement for senior medical assessment, is provided through the National Infection Prevention and Control Manual (NIPCM) and Scottish Antimicrobial Prescribing Group (SAPG) frameworks. SAPG guidance also addresses timely CDI-specific antibiotic therapy (ARHAI Scotland / NIPCM, 2022-07-11).
NHS Health Boards (Scotland)
(Primary)
View Details
Medical record keeping
Recommendation
Health Boards should ensure that clear, accurate and legible patient records are kept by doctors, that records are seen as integral to good patient care.
Published evidence summary
The Scottish Government accepted this recommendation in 2015. The General Medical Council (GMC) requires doctors to maintain clear, accurate, and legible records, and the Scottish Government developed its Records Management: NHS code of practice (Scotland), updated in 2012. The Excellence in Care framework and NHS Scotland governance standards address medical record keeping requirements, with electronic health record systems being rolled out across NHS Scotland to address legibility concerns (Healthcare Improvement Scotland, 2025-01-01).
NHS Health Boards (Scotland)
(Primary)
View Details
DNAR decision awareness
Recommendation
Health Boards should ensure that medical and nursing staff are aware that a DNAR1 decision is an important aspect of care.
Published evidence summary
The Scottish Government accepted this recommendation in 2015. The Scottish Government published the Do Not Attempt Cardiopulmonary Resuscitation (DNACPR) Integrated Adult Policy in 2016, which provides a standardised national approach to DNAR decisions. Subsequent updates to this policy have addressed communication requirements with patients and families regarding DNACPR decisions (Scottish Government, 2015-06-18, with 2016 policy publication).
NHS Health Boards (Scotland)
(Primary)
View Details
Prudent antibiotic prescribing
Recommendation
Health Boards should ensure that the key principles of prudent antibiotic prescribing are adhered to and that implementation of policy is rigorously monitored by management.
Published evidence summary
The Scottish Government accepted this recommendation in 2015. The Scottish Antimicrobial Prescribing Group (SAPG) provides comprehensive prudent antibiotic prescribing guidance, including hospital and community antimicrobial stewardship good practice recommendations. National monitoring of prescribing trends continues, with SAPG having operated since 2008 and demonstrating improvements in prescribing patterns (SAPG, 2025-01-01).
NHS Health Boards (Scotland)
(Primary)
View Details
Laboratory specimen processing
Recommendation
Health Boards should ensure that there is no unnecessary delay in processing laboratory specimens, in reporting positive results and in commencing specific antibiotic treatment.
Published evidence summary
The Scottish Government accepted this recommendation in 2015. The National Infection Prevention and Control Manual (NIPCM) provides guidance on laboratory specimen handling and CDI testing. A national surveillance system requires timely reporting of positive results, and CDI testing turnaround times are monitored as part of national surveillance quality indicators (ARHAI Scotland / NIPCM, 2022-07-11).
NHS Health Boards (Scotland)
(Primary)
View Details
Mandatory IPC training
Recommendation
Health Boards should ensure that all those working in a healthcare setting have mandatory infection prevention control training that includes CDI on appointment.
Published evidence summary
The Scottish Government accepted this recommendation in 2015. The Scottish Infection Prevention and Control Education Pathway (SIPCEP) provides mandatory IPC training, with the IPC Zone available on the Turas Learn platform. Healthcare Improvement Scotland (HIS) published new Infection Prevention and Control Standards in May 2022, which apply to all health and adult social care settings in Scotland and require all staff to receive appropriate IPC training on appointment and regularly thereafter (NHS Education for Scotland, 2025-01-01; Healthcare Improvement Scotland, 2022-05-01).
NHS Health Boards (Scotland)
(Primary)
View Details
IPC staff regular training
Recommendation
Health Boards should ensure that Infection Control Nurses and Infection Control Doctors have regular training in infection prevention and control of which a record should be kept.
Published evidence summary
The Scottish Government accepted this recommendation in 2015. The Scottish Infection Prevention and Control Education Pathway (SIPCEP) includes a specialist IPC training pathway. The Infection Prevention Workforce Strategic Plan 2022-2024 addresses IPC specialist career development and continuing education, and a new IPC Specialist Career Framework is currently under development (NHS Education for Scotland, 2025-01-01).
NHS Health Boards (Scotland)
(Primary)
View Details
IPC staff appraisals
Recommendation
Health Boards should ensure that performance appraisals of infection prevention and control staff take place at least annually.
Published evidence summary
The Scottish Government accepted this recommendation in 2015. Healthcare Improvement Scotland (HIS) IPC Standards (2022) Standard 1 (Leadership and Governance) includes requirements for IPC staff performance management. The Infection Prevention Workforce Strategic Plan 2022-2024 also addresses workforce development, providing a national standards framework for IPC staff appraisal requirements (Healthcare Improvement Scotland, 2022-05-01).
NHS Health Boards (Scotland)
(Primary)
View Details
Manager IPC job description
Recommendation
Health Boards should ensure that where a manager has responsibility for oversight of infection prevention control, this is specified in the job description.
Published evidence summary
The Scottish Government accepted this recommendation in 2015. Healthcare Improvement Scotland (HIS) IPC Standards (2022) Standard 1 (Leadership and Governance) specifies requirements for IPC management roles and responsibilities within health boards. These national standards provide a framework for IPC management accountability, including job description requirements for managers with IPC oversight (Healthcare Improvement Scotland, 2022-05-01).
NHS Health Boards (Scotland)
(Primary)
View Details
ICM direct responsibility
Recommendation
Health Boards should ensure that the Infection Control Manager has direct responsibility for the infection prevention control service and its staff.
Published evidence summary
The Scottish Government accepted this recommendation in 2015. The Scottish Government's response explicitly states the Infection Control Manager (ICM) has overall responsibility for coordinating infection prevention and control. Healthcare Improvement Scotland (HIS) IPC Standards (2022) Standard 1 further addresses IPC management structure and the ICM's direct responsibility for IPC services (Scottish Government, 2015-06-18; Healthcare Improvement Scotland, 2022-05-01).
NHS Health Boards (Scotland)
(Primary)
View Details
ICM reports to CEO
Recommendation
Health Boards should ensure that the Infection Control Manager reports direct to the Chief Executive or, at least, to an executive board member.
Published evidence summary
The Scottish Government accepted this recommendation in 2015, stating the Infection Control Manager (ICM) is accountable directly to the chief executive and the board, and Healthcare Improvement Scotland (HIS) IPC Standards (2022) Standard 1 addresses reporting structures for IPC. However, the QEUH Oversight Board found in 2021 that key IPC information was not escalated to senior management and the Board within NHS GGC, indicating that direct ICM reporting to the CEO/board was not effectively implemented in that health board (Scottish Government, 2015-06-18; Healthcare Improvement Scotland, 2022-05-01; Scottish Government Oversight Board, 2021-03-01).
NHS Health Boards (Scotland)
(Primary)
View Details
ICM Board HAI reporting
Recommendation
Health Boards should ensure that the ICM is responsible for reporting to the Board on the state of HAI in the organisation.
Published evidence summary
The Scottish Government accepted this recommendation in 2015, stating the Infection Control Manager (ICM) is responsible for producing an annual public report on the state of HAI and is accountable to the chief executive and the board. Healthcare Improvement Scotland (HIS) IPC Standards (2022) Standard 1 and Standard 4 require systematic monitoring and reporting of HAI data to Board level, with compliance monitored through HIS inspections (Scottish Government, 2015-06-18; Healthcare Improvement Scotland, 2022-05-01).
NHS Health Boards (Scotland)
(Primary)
View Details
National ICM role guidance
Recommendation
Scottish Government should re-issue national guidance on the role of the ICM, stipulating that the ICM must be responsible for the management of the infection prevention and control service.
Published evidence summary
According to the Scottish Government, this recommendation was accepted in 2015 and the government committed to re-issuing national guidance on the Infection Control Manager (ICM) role. According to the Infection Prevention Workforce Strategic Plan 2022-2024, the ICM role is addressed nationally, and according to Healthcare Improvement Scotland (HIS) IPC Standards (2022) Standard 1, a framework for ICM responsibilities is provided; furthermore, according to Scottish Government / ARHAI Scotland (2022-01-01), national guidance has been reissued through multiple channels, with ARHAI Scotland providing national coordination (Scottish Government, 2015-03-01).
Scottish Government
(Primary)
View Details
24/7 IPC cover
Recommendation
Health Boards should ensure that there is 24-hour cover for infection prevention and control seven days a week, and that contingency plans for leave and sickness absence are in place.
Published evidence summary
According to Healthcare Improvement Scotland (2022-05-01), Healthcare Improvement Scotland's (HIS) IPC Standards (2022) address the requirements for 24-hour, seven-day-a-week infection prevention and control (IPC) cover. According to Healthcare Improvement Scotland (2022-05-01), the Infection Prevention Workforce Strategic Plan 2022-2024 also addresses workforce planning for IPC services, including contingency arrangements for leave and sickness absence. According to the available evidence, the Scottish Government accepted this recommendation in 2015.
NHS Health Boards (Scotland)
(Primary)
View Details
ICT functions as team
Recommendation
Health Boards should ensure that any Infection Control Team functions as a team, with clear lines of communication and regular meetings.
Published evidence summary
According to Healthcare Improvement Scotland (2022-05-01), Healthcare Improvement Scotland's (HIS) IPC Standards (2022), specifically Standard 1 (Leadership and Governance), address the requirements for Infection Control Teams (ICTs) to function effectively with clear communication lines and regular meetings. According to Healthcare Improvement Scotland (2022-05-01), the Infection Prevention Workforce Strategic Plan 2022-2024 also addresses team structures, and board-level compliance is monitored through HIS inspections. According to the available evidence, the Scottish Government accepted this recommendation in 2015.
NHS Health Boards (Scotland)
(Primary)
View Details
IPC policy adherence audits
Recommendation
Health Boards should ensure that adherence to infection prevention and control polices, for example C. difficile and Loose Stools Policies, is audited at least annually.
Published evidence summary
According to Healthcare Improvement Scotland (2022-05-01), Healthcare Improvement Scotland's (HIS) IPC Standards (2022), Standard 4 (Assurance and Monitoring), requires systematic auditing of infection prevention and control (IPC) policy adherence. According to Healthcare Improvement Scotland (2022-05-01), the National Infection Prevention and Control Manual (NIPCM) provides audit tools for download, and national compliance is monitored through HIS inspections. According to the available evidence, the Scottish Government accepted this recommendation in 2015.
NHS Health Boards (Scotland)
(Primary)
View Details
Surveillance systems fit for purpose
Recommendation
Health Boards should ensure that surveillance systems are fit for purpose, are simple to use and monitor, and provide information on potential outbreaks in real time.
Published evidence summary
According to Public Health Scotland / NSS (2025-09-01), national mandatory Clostridioides difficile infection (CDI) surveillance has been operational across NHS Scotland since 2006 for patients aged 65+ and 2009 for all patients aged 15+, with real-time surveillance systems in place and quarterly epidemiological data published. According to Public Health Scotland (2024-11-04), dedicated guidance was also published in November 2024 for the prevention and control of CDI in community-based settings, extending surveillance beyond hospitals. According to the Scottish Government's response, this recommendation was accepted in 2015.
NHS Health Boards (Scotland)
(Primary)
View Details
Surveillance system training
Recommendation
Health Boards should ensure that the users of surveillance systems are properly trained in their use and fully aware of how to use and respond to the data available.
Published evidence summary
According to Healthcare Improvement Scotland (2022), Standard 4 (Assurance and Monitoring) of its IPC Standards addresses surveillance system training requirements. According to Healthcare Improvement Scotland (2022-05-01), the Scottish Infection Prevention and Control Education Pathway (SIPCEP) includes surveillance system training as part of its IPC education pathway, ensuring users are properly trained. According to the Scottish Government's response, this recommendation was accepted in 2015.
NHS Health Boards (Scotland)
(Primary)
View Details
CDI reporting to CEO and Board
Recommendation
Health Boards should ensure that numbers and rates of CDI are reported through each level of the organisation up to the Chief Executive and the Board.
Published evidence summary
According to Public Health Scotland / NSS (2025-09-01), Clostridioides difficile infection (CDI) rates are reported through multiple levels of organisation, from ward to Board level, with quarterly national surveillance reports published. According to the Scottish Government Oversight Board (2021-03-01), however, the QEUH Oversight Board identified significant failings in the reporting of infection data within NHS Greater Glasgow and Clyde in March 2021, indicating ongoing challenges in appropriate escalation despite the national framework. According to the Scottish Government's response, this recommendation was accepted in 2015.
NHS Health Boards (Scotland)
(Primary)
View Details
Regular IPC group meetings
Recommendation
Health Boards should ensure that infection prevention and control groups meet at regular intervals and that there is appropriate reporting upwards through the management structure.
Published evidence summary
According to Healthcare Improvement Scotland (2022), Standard 1 (Leadership and Governance) of its IPC Standards requires regular infection prevention and control (IPC) committee meetings with appropriate upward reporting through the management structure. According to Healthcare Improvement Scotland (2022-05-01), compliance with these requirements is monitored through HIS inspections. According to the Scottish Government's response, this recommendation was accepted in 2015.
NHS Health Boards (Scotland)
(Primary)
View Details
IPC committee minutes reporting
Recommendation
Health Boards should ensure that the minutes of all meetings and reports from each infection prevention and control committee are reported to the level above in the hierarchy.
Published evidence summary
According to Healthcare Improvement Scotland (2022), Standard 1 (Leadership and Governance) of its IPC Standards addresses reporting requirements between infection prevention and control (IPC) committees at different governance levels. According to Healthcare Improvement Scotland (2022-05-01), this ensures that minutes of meetings and reports from each committee are reported to the level above in the hierarchy. According to the Scottish Government's response, this recommendation was accepted in 2015.
NHS Health Boards (Scotland)
(Primary)
View Details
Lay representation on IPC committee
Recommendation
Health Boards should ensure that there is lay representation at Board infection prevention and control committee level in keeping with local policy on public involvement.
Published evidence summary
According to Healthcare Improvement Scotland (2022), its IPC Standards address governance requirements for infection prevention and control committees. According to Healthcare Improvement Scotland (2022-05-01), Scottish Government public involvement standards require patient and public representation in NHS governance, supporting lay representation at Board IPC committee level. According to the Scottish Government's response, this recommendation was accepted in 2015.
NHS Health Boards (Scotland)
(Primary)
View Details
Priority attendance at IPC meetings
Recommendation
Health Boards should ensure that attendance by members of committees in the infection prevention and control structure is treated as a priority.
Published evidence summary
According to Healthcare Improvement Scotland (2022), Standard 1 (Leadership and Governance) of its IPC Standards addresses attendance requirements for infection prevention and control (IPC) governance meetings, treating participation as a priority. According to Healthcare Improvement Scotland (2022-05-01), compliance is monitored through HIS inspections. According to the Scottish Government's response, this recommendation was accepted in 2015.
NHS Health Boards (Scotland)
(Primary)
View Details
Cleanliness Champions implementation
Recommendation
Health Boards should ensure that programmes designed to improve staff knowledge of good infection prevention and control practice, such as Cleanliness Champions Programme, are implemented without undue delay.
Published evidence summary
According to NHS Education for Scotland (2025-01-01), the Cleanliness Champions Programme, which trained over 18,000 healthcare workers, is now integrated into the Scottish Infection Prevention and Control Education Pathway (SIPCEP). According to NHS Education for Scotland (2025-01-01), this pathway provides a staged approach to IPC education via the Turas Learn platform, ensuring ongoing staff knowledge of good IPC practice. According to the Scottish Government's response, this recommendation was accepted in 2015.
NHS Health Boards (Scotland)
(Primary)
View Details
Unannounced inspections with lay representation
Recommendation
Health Boards should ensure that unannounced inspections of clinical areas are conducted by senior infection prevention and control staff accompanied by lay representation.
Published evidence summary
According to Healthcare Improvement Scotland (2024-01-01), the Healthcare Environment Inspectorate (HEI) conducts unannounced inspections of clinical areas, with over 200 inspections since its inception and at least 30 annually. According to Healthcare Improvement Scotland (2024-01-01), public partners participate in some inspection activities to ensure a patient and public view. According to the Scottish Government's response, this recommendation was accepted in 2015.
NHS Health Boards (Scotland)
(Primary)
View Details
Senior manager clinical visits
Recommendation
Health Boards should ensure that senior managers accompanied by IPC staff visit clinical areas at least weekly to verify that proper attention is being paid to IPC.
Published evidence summary
According to Healthcare Improvement Scotland (2022), its IPC Standards address management oversight of clinical areas, including senior manager visits with IPC staff. According to Healthcare Improvement Scotland (2022-05-01), while governance standards address these visits, compliance is noted to vary across different health boards. According to the Scottish Government's response, this recommendation was accepted in 2015.
NHS Health Boards (Scotland)
(Primary)
View Details
Effective CDI patient isolation
Recommendation
Health Boards should ensure that there is effective isolation of any patient who is suspected of suffering from CDI, and that failure to isolate is reported to senior management.
Published evidence summary
According to Scottish Government policy (CEL 48 2008), all planned new-build hospitals must provide 100% single-room accommodation and refurbished buildings at least 50% single rooms, along with specific bed spacing requirements for multi-bed wards. According to the Scottish Government (2008-01-01), the National Infection Prevention and Control Manual (NIPCM) provides detailed isolation guidance. According to the Scottish Government's response, this recommendation was accepted in 2015, but the core policy evidence is from 2008.
NHS Health Boards (Scotland)
(Primary)
View Details
Cohorting only exceptional
Recommendation
Health Boards should ensure that cohorting is not used as a substitute for single room isolation and is only resorted to in exceptional circumstances.
Published evidence summary
According to the Scottish Government response, 18 June 2015, the Scottish Government established a policy requiring 100% single-room accommodation in new-build hospitals and at least 50% in refurbished hospitals to minimise the need for cohorting. According to ARHAI Scotland / NIPCM, 11 July 2022, detailed guidance from ARHAI Scotland's National Infection Prevention and Control Manual (NIPCM), updated in July 2022, restricts cohorting to exceptional circumstances when single rooms are unavailable, reinforcing single-room isolation as the default.
NHS Health Boards (Scotland)
(Primary)
View Details
Isolation for infectious diarrhoea
Recommendation
Health Boards should ensure that appropriate steps are taken to isolate patients with potentially infectious diarrhoea.
Published evidence summary
According to the Scottish Government response, 18 June 2015, the Scottish Government's response highlighted Standard Infection Control Precautions (SICPs), including patient placement, and a policy for increased single-room accommodation in hospitals to reduce infection risks. According to ARHAI Scotland / NIPCM, 11 July 2022, ARHAI Scotland's National Infection Prevention and Control Manual (NIPCM), continuously updated, provides comprehensive guidance on isolating patients with potentially infectious diarrhoea, detailing SICPs and transmission-based precautions.
NHS Health Boards (Scotland)
(Primary)
View Details
Healthcare environment maintenance
Recommendation
Health Boards should ensure that the healthcare environment does not compromise effective IPC, and that poor maintenance practices are not tolerated.
Published evidence summary
According to the Scottish Government response, 18 June 2015, the Scottish Government introduced a revised NHSScotland National Cleaning Services Specification and monitoring framework, alongside over £400 million investment in NHS estates between 2014 and 2016, to improve the healthcare environment. According to Healthcare Improvement Scotland, 1 May 2022, Healthcare Improvement Scotland's (HIS) IPC Standards (2022) include Standard 8 (Built Environment) and Standard 7 (Equipment Cleaning), which require healthcare environments to support effective infection prevention and control, with compliance assessed through HEI inspections.
NHS Health Boards (Scotland)
(Primary)
View Details
Link Nurse training
Recommendation
Health Boards should ensure that, where a local Link Nurse system is in place as part of the IPS system, the Link Nurses have specific training for that role.
Published evidence summary
According to the Scottish Government response, 18 June 2015, the Scottish Government's response outlined support for education and training for healthcare workers and IPC specialists, including postgraduate programs. According to NHS Education for Scotland, 1 January 2025, NHS Education for Scotland has implemented the Scottish Infection Prevention and Control Education Pathway (SIPCEP), which incorporates specific training for Link Nurses/Link Practitioners as part of a staged education pathway, with role-specific resources available on the Turas Learn platform.
NHS Health Boards (Scotland)
(Primary)
View Details
Consultant involvement in death certificates
Recommendation
Health Boards should ensure that where a death occurs in hospital the consultant in charge of the patients care is involved in completion of the death certificate wherever practicable.
Published evidence summary
According to the Scottish Parliament, 13 May 2015, the Certification of Death (Scotland) Act 2011 came into force on 13 May 2015, directly addressing the statutory reform of death certification. According to the available evidence, this legislation is supported by the Death Certification Review Service (DCRS) within Healthcare Improvement Scotland, which conducts random reviews of approximately 12% of all death certificates to ensure accuracy and consultant involvement where practicable. No further published evidence has been identified since 2015.
NHS Health Boards (Scotland)
(Primary)
View Details
Explanation to relatives on CDI death
Recommendation
Health boards should ensure that if a patient dies with CDI either as a cause of death or as a condition contributing to the death, relatives are provided with a clear explanation.
Published evidence summary
According to the Scottish Government, 1 April 2018, the Scottish Government established a statutory Duty of Candour under the Health (Tobacco Nicotine etc. and Care) (Scotland) Act 2016, with the Duty of Candour Procedure (Scotland) Regulations 2018 requiring organisations to inform families, apologise, and provide explanations for safety incidents, including when CDI contributes to death. According to the Scottish Government Oversight Board, 1 March 2021, the Queen Elizabeth University Hospital (QEUH) Oversight Board found in March 2021 that the Duty of Candour was not formally activated for specific infection instances at QEUH, despite deaths linked to the hospital environment, indicating a gap in practical application.
NHS Health Boards (Scotland)
(Primary)
View Details
COPFS death reporting guidance review
Recommendation
Crown Office and the Procurator Fiscal service (COPFS) should review its guidance on the reporting of deaths regularly and at least every two years.
Published evidence summary
According to the Scottish Government response, 18 June 2015, the Scottish Government requested the Crown Office and Procurator Fiscal Service (COPFS) to assess progress on this recommendation in December 2014. According to the available evidence, COPFS confirmed it would regularly review its guidance on death reporting and has since revised its Guidance on Investigation of Deaths. However, no publicly available evidence confirms the formal adoption of a specific two-yearly review cycle as recommended. No further published evidence has been identified since 2015.
COPFS
(Primary)
View Details
National CDI death monitoring
Recommendation
Scottish Government should identify a national agency to undertake routine national monitoring of deaths related to CDI.
Published evidence summary
According to the Scottish Government, 1 March 2015, the Scottish Government identified national agencies for routine monitoring of C. difficile-related deaths, implemented through existing HAI surveillance structures and Healthcare Improvement Scotland oversight. According to Public Health Scotland / NSS, 1 September 2025, Public Health Scotland and ARHAI Scotland now undertake national mandatory CDI surveillance, which includes the monitoring of CDI-related deaths, with quarterly reports published and comprehensive surveillance work reflected in the ARHAI Scotland 2024 Annual Report.
Scottish Government
(Primary)
View Details
Internal investigation independence
Recommendation
Health Boards should ensure that a non-executive Board Member or a representative from internal audit takes part in an Internal Investigation.
Published evidence summary
According to the Scottish Government response, 18 June 2015, the Scottish Government's response indicated that requirements for internal investigation independence are addressed through existing governance frameworks and the Code of Corporate Governance for NHS Scotland. According to the available evidence, however, no specific new mechanism mandating the participation of a non-executive Board Member or a representative from internal audit in all internal investigations has been publicly confirmed since 2015.
NHS Health Boards (Scotland)
(Primary)
View Details
OCT report detail sufficiency
Recommendation
Health Boards should ensure that OCT3 reports provide sufficient details of the key factors in the spread of infection to allow a proper audit to be carried out.
Published evidence summary
According to the Scottish Government response, 18 June 2015, the Scottish Government's response indicated that outbreak control team reporting requirements are addressed, with the National Infection Prevention and Control Manual (NIPCM) providing detailed guidance on Outbreak Control Team (OCT) reporting standards. According to the available evidence, however, no specific enforcement mechanism to ensure OCT reports provide sufficient details of key factors in infection spread for proper auditing has been publicly confirmed since 2015.
NHS Health Boards (Scotland)
(Primary)
View Details
Review of UK IPC reports
Recommendation
Scottish Government (whether through HPS, HIS, the HAI Task Force or otherwise) should as a matter of standard practice ensure that reports published in the UK and in other relevant jurisdictions on infection prevention and control and patient safety are …
Read more
Published evidence summary
According to the Scottish Government response, 18 June 2015, the Scottish Government's response acknowledged the need for timely review of relevant measures from inquiry reports, including those from other jurisdictions. According to ARHAI Scotland, 1 January 2025, ARHAI Scotland (Antimicrobial Resistance and Healthcare Associated Infection Scotland) now serves as the national body responsible for reviewing UK and international infection prevention and control reports as standard practice. According to the available evidence, its National Policies Guidance and Evidence Working Group continuously reviews published literature and reports to inform NIPCM updates and national policy development.
Scottish Government
(Primary)
View Details
Health Board review of IPC reports
Recommendation
Health Boards should review such reports to determine what lessons can be learned and what reviews, audits or other measures (interim or otherwise) should be put in place.
Published evidence summary
According to the Scottish Government response, 18 June 2015, the Scottish Government's response highlighted the recommendation for NHS boards to review external inquiry reports for learning and implementation of necessary measures. According to Healthcare Improvement Scotland, 1 May 2022, Healthcare Improvement Scotland's (HIS) IPC Standards (2022) include Standard 6 (Evidence-Based Policies), which explicitly requires health boards to review published reports and update their policies accordingly. According to the available evidence, compliance with learning from external reports is assessed through HEI inspections.
NHS Health Boards (Scotland)
(Primary)
View Details