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Vale of Leven Hospital Inquiry

Completed

Vale of Leven Inquiry

Chair The Rt Hon Lord MacLean Judge / Judiciary
Established 21 Aug 2009
Final Report 24 Nov 2014
Commissioned by Scottish Government

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.

Evidence & Impact
The Vale of Leven Hospital Inquiry was established in November 2009 following an outbreak of Clostridium difficile infection at the hospital between December 2007 and June 2008. Lord MacLean's inquiry examined the circumstances surrounding the outbreak and made 75 recommendations in November 2014 aimed at preventing similar incidents.

The Scottish Government accepted all 75 recommendations. The government response describes various initiatives and frameworks already in place or subsequently developed that align with the inquiry's recommendations. These include the Healthcare Environment Inspectorate providing independent scrutiny of hospitals, the National Infection Prevention and Control Manual introduced in 2012, and revised Healthcare Associated Infection Standards published in 2015.

The response identifies reforms to professional standards, particularly the revised NMC code requiring improved record-keeping by nurses, and initiatives to enhance patient communication through the Person-centred Health and Care Collaborative. Investment in NHS infrastructure exceeded £400 million between 2014-2016, with formula-based funding for routine maintenance rising to £157.2 million in 2015/16.

Education and training initiatives include the Cleanliness Champions Programme completed by over 18,000 staff and accredited programmes for specialist roles. The Scottish Antimicrobial Prescribing Group works with NHS boards to maintain stewardship activities, supported by the Scottish Management of Antimicrobial Resistance Action Plan 2014-18.

However, no published evidence of progress updates or implementation reviews has been identified for any of the 75 recommendations since the inquiry reported. While the government response describes various relevant policies and frameworks, it does not provide specific evidence that certain key recommendations have been actioned, including giving HEI powers to close wards, establishing dedicated local HAI Task Forces, or implementing specific DNAR awareness initiatives. The absence of documented progress updates 11 years after publication raises questions about the extent to which the inquiry's recommendations have been systematically monitored and implemented.
Reforms Attributed to This Inquiry
- Healthcare Environment Inspectorate (HEI) established to provide independent scrutiny of NHS Scotland hospitals with powers to issue requirements for action to comply with national HAI standards
- National Infection Prevention and Control Manual introduced January 2012 providing NHS boards with evidence-based guidance on infection prevention and control
- Revised Healthcare Associated Infection (HAI) Standards published February 2015 for adoption by NHS boards from May 2015
- Standard Infection Control Precautions (SICP) framework established including specific guidance on patient placement in wards and bays
- Revised NMC code (March 2015) requiring nurses to maintain clear, accurate and contemporaneous records
- Scottish Management of Antimicrobial Resistance Action Plan 2014-18 and Controlling Antimicrobial Resistance in Scotland Group established
- Cleanliness Champions Programme completed by over 18,000 staff to promote infection prevention culture
- Leading Better Care initiative strengthening role of senior charge nurses as clinical leaders
- Person-centred Health and Care Collaborative developing 'Must Do with Me' elements for patient communication
- Health Literacy Action Plan and appointment of Clinical Lead for Health Literacy
- Mandatory nursing and midwifery workload and workforce planning tools implemented across all NHS boards
- Records Management: NHS code of practice (Scotland) updated 2012
Unfinished Business
- No evidence that HEI has been given power to close wards to new admissions as recommended
- No evidence of dedicated local HAI Task Forces within each Health Board area
- No evidence of specific policy requiring complaints about nursing practice to be investigated by independent senior member of Nursing Management
- No evidence of specific DNAR awareness initiatives for staff beyond acknowledgement of recommendation
- No evidence of annual appraisals specifically for all IPC staff
- No evidence that infection prevention and control oversight has been specified in job descriptions of other managers beyond the Infection Control Manager
AI-generated narrative. Generated 26 Mar 2026 using claude-opus-4. Assessment is indicative, not authoritative.
5 years, 3 months Duration
Inquiry Website
Government Response
Accepted 75
Total Recommendations 75
Data last updated: 18 Jun 2015 · Source
Data verified: 26 May 2026 (import)
How to read this

Government Response tracks what the government said it would do (accepted, rejected, etc.).

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All Activity (6)
Title Volume Publication Date Tracked recs Links
The Vale of Leven Hospital Inquiry Report Final Report 24 Nov 2014 75
01 May 2009
Inquiry Announced
01 Nov 2009
Inquiry Established
24 Nov 2014
Final Report Published

Recommendations (75)

R1
Accepted
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
- The Scottish Government published its response to the Vale of Leven Hospital Inquiry Report on 18 June 2015, accepting all 75 recommendations and establishing an Implementation Group chaired by the Chief Nursing Officer (Scottish Government Response, June 2015).
- Healthcare Improvement Scotland (HIS), established on 1 April 2011 under the Public Services Reform (Scotland) Act 2010, absorbed the functions of the Healthcare Environment Inspectorate (HEI). HIS has the power to direct a Health Board to close a ward to new admissions where there is a serious risk to the life, health or wellbeing of persons (HIS Operating Framework, Scottish Government).
- HIS conducts both announced and unannounced inspections of healthcare facilities, including assessment of infection prevention and control standards. The Healthcare Improvement Scotland (Inspections) Regulations 2011 provide the statutory basis for these inspection powers.
- The revised Healthcare Associated Infection Standards, published by HIS in February 2015, provide the framework against which HIS assesses compliance, with escalation powers including ward closure available where serious risks are identified.
- This recommendation has been implemented: HIS has the statutory power to close wards to new admissions where patient safety is at risk.
Scottish Government (Primary)
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R2
Accepted
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
- The Scottish Government published its response to the Vale of Leven Hospital Inquiry Report on 18 June 2015, accepting all 75 recommendations and establishing an Implementation Group chaired by the Chief Nursing Officer (Scottish Government Response, June 2015).
- Revised Healthcare Associated Infection Standards were published by HIS in February 2015, which NHS boards adopted from May 2015. The standards were accompanied by an implementation framework specifying how compliance would be monitored through the HIS inspection programme.
- The National Infection Prevention and Control Manual (NIPCM) for Scotland, first published on 13 January 2012 and relaunched on 11 July 2022, provides evidence-based practice guidance for all healthcare workers. Scotland was the first country to develop a national IPC manual, and it is accompanied by implementation support from ARHAI Scotland (National Infection Prevention and Control Manual for Scotland (https://www.nipcm.hps.scot.nhs.uk/about-the-manual/)).
- The Scottish HCAI Strategy 2023-2025 sets out the current strategic framework for reducing healthcare-associated infections, with implementation monitored through the HCAI Strategy Oversight Board chaired by the Chief Nursing Officer (Scottish HCAI Strategy 2023-2025 (https://www.gov.scot/publications/scottish-healthcare-associated-infection-hcai-strategy-2023-2025/)).
- The pattern of policy accompanied by implementation strategy and monitoring is now established practice in Scottish HAI governance.
Scottish Government (Primary)
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R3
Accepted
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
- The Scottish Government published its response to the Vale of Leven Hospital Inquiry Report on 18 June 2015, accepting all 75 recommendations and establishing an Implementation Group chaired by the Chief Nursing Officer (Scottish Government Response, June 2015).
- The NIPCM for Scotland is maintained as a living document, regularly updated in response to new evidence, emerging infections, and changes in national or international guidance. The manual was relaunched on 11 July 2022 to reflect lessons from the COVID-19 pandemic (National Infection Prevention and Control Manual for Scotland (https://www.nipcm.hps.scot.nhs.uk/about-the-manual/)).
- NHS boards are required to adhere to the revised HAI Standards and the NIPCM. Healthcare Improvement Scotland monitors compliance through announced and unannounced inspections.
- The HCAI Strategy 2023-2025 includes mechanisms for reviewing and updating infection prevention and control policies in response to emerging threats, with ARHAI Scotland providing scientific advice and surveillance data to inform policy updates (Scottish HCAI Strategy 2023-2025 (https://www.gov.scot/publications/scottish-healthcare-associated-infection-hcai-strategy-2023-2025/)).
- The recommendation for prompt policy review in response to new guidance is addressed through the NIPCM's living document approach and the governance structure of the HCAI Strategy Oversight Board.
NHS Health Boards (Scotland) (Primary)
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R4
Accepted
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 published its response to the Vale of Leven Hospital Inquiry Report on 18 June 2015, accepting all 75 recommendations and establishing an Implementation Group chaired by the Chief Nursing Officer (Scottish Government Response, June 2015).
- The Scottish Government committed to restructuring the national HAI Taskforce into a smaller, more focused group working with local teams and existing structures in NHS boards. The government committed to supporting NHS board-level HAI governance structures linked to the national Taskforce.
- The current strategic framework, the Scottish HCAI Strategy 2023-2025, is overseen by the HCAI Strategy Oversight Board chaired by the Chief Nursing Officer, with representation from Scottish Government, expert stakeholders, and National Health Boards (Scottish HCAI Strategy 2023-2025 (https://www.gov.scot/publications/scottish-healthcare-associated-infection-hcai-strategy-2023-2025/)).
- Key partner agencies include ARHAI Scotland (Antimicrobial Resistance and Healthcare Associated Infection Scotland) and Public Health Scotland, which provide national surveillance, scientific advice, and implementation support to NHS boards.
- Each NHS board maintains local infection prevention and control governance structures, with Infection Control Managers reporting to chief executives and boards as required by the HAI Standards.
Scottish Government (Primary)
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R5
Accepted
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
- The Scottish Government published its response to the Vale of Leven Hospital Inquiry Report on 18 June 2015, accepting all 75 recommendations and establishing an Implementation Group chaired by the Chief Nursing Officer (Scottish Government Response, June 2015).
- The Scottish Government's response outlined broader health policy initiatives including the 2020 Vision and the integration of health and social care, aiming to resolve uncertainties about hospital and service futures through strategic planning.
- The Public Bodies (Joint Working) (Scotland) Act 2014 established Integration Authorities for health and social care, providing a framework for strategic commissioning decisions about service configuration. This was intended to reduce uncertainty about the future of local services.
- However, this recommendation is inherently ongoing and difficult to assess as fully implemented: decisions about hospital futures continue to arise as demographic and clinical needs change. The Scottish Government's approach has been to embed service reconfiguration decisions within strategic planning frameworks rather than to establish a specific mechanism guaranteeing timely resolution of uncertainty.
- The closure of the Vale of Leven Hospital's inpatient services, which was a source of uncertainty at the time of the inquiry, has been resolved through the NHS Greater Glasgow and Clyde health board's service planning process.
Scottish Government (Primary)
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R6
Accepted
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
- The Scottish Government published its response to the Vale of Leven Hospital Inquiry Report on 18 June 2015, accepting all 75 recommendations and establishing an Implementation Group chaired by the Chief Nursing Officer (Scottish Government Response, June 2015).
- The Scottish Government's response detailed the requirement for clear and effective continuity plans when major changes in patient services are planned, embedded within the broader framework for health and social care integration.
- The Health and Care (Staffing) (Scotland) Act 2019 (provisions in force from 1 April 2024) places duties on NHS Health Boards to ensure appropriate staffing levels during all periods including service transitions, requiring real-time identification of staffing risks and procedures to address them (Health and Care (Staffing) (Scotland) Act 2019 (https://www.legislation.gov.uk/asp/2019/6)).
- Healthcare Improvement Scotland's role in scrutinising service changes provides external assurance that patient safety is maintained during transitions. HIS has the power to intervene, including directing ward closures, where patient safety is at risk.
- The Scottish Patient Safety Programme (SPSP), launched in 2008, provides a framework for maintaining safety standards during periods of organisational change, with Patient Safety Essentials embedded across NHS Scotland.
Scottish Government (Primary)
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R7
Accepted
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
- The Scottish Government published its response to the Vale of Leven Hospital Inquiry Report on 18 June 2015, accepting all 75 recommendations and establishing an Implementation Group chaired by the Chief Nursing Officer (Scottish Government Response, June 2015).
- The Scottish Government's response confirmed that clinical and care governance frameworks, including due diligence and risk assessment processes, should be undertaken during any major structural reorganisation. The 'Governance for Quality Healthcare in Scotland' agreement provides the framework for governance during organisational change.
- The Public Bodies (Joint Working) (Scotland) Act 2014 required formal governance arrangements for the integration of health and social care, including risk assessment and due diligence processes for the transfer of functions to Integration Authorities.
- Healthcare Improvement Scotland provides external assurance of governance arrangements, with powers to inspect and report on the quality of care during and after structural changes.
NHS Health Boards (Scotland) (Primary)
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R8
Accepted
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
- The Scottish Government published its response to the Vale of Leven Hospital Inquiry Report on 18 June 2015, accepting all 75 recommendations and establishing an Implementation Group chaired by the Chief Nursing Officer (Scottish Government Response, June 2015).
- The Scottish Government's response emphasised that leaders and managers at all levels are responsible for quality of care, and that investment is needed in leadership and management during structural change. Work was underway on a leadership and management framework for NHS Scotland.
- The integration of health and social care under the Public Bodies (Joint Working) (Scotland) Act 2014 required each Integration Authority to establish management structures ensuring continuity of safe patient care during the transition.
- The Health and Social Care Standards (published June 2017, in use from April 2018) set expectations for governance and management across health and social care, providing a benchmark for management effectiveness during and after reorganisation (Health and Social Care Standards (https://www.gov.scot/publications/health-social-care-standards-support-life/)).
NHS Health Boards (Scotland) (Primary)
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R9
Accepted
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
- The Scottish Government published its response to the Vale of Leven Hospital Inquiry Report on 18 June 2015, accepting all 75 recommendations and establishing an Implementation Group chaired by the Chief Nursing Officer (Scottish Government Response, June 2015).
- The Scottish Government's response confirmed that the Infection Control Manager is an integral member of the organisation's infection prevention and control, clinical governance, and risk management frameworks. The revised HAI Standards require infection prevention and control to be considered at all levels of governance from ward to board.
- The HCAI Strategy 2023-2025 reinforces the requirement for HAI governance to be embedded within clinical governance structures at every level of NHS boards (Scottish HCAI Strategy 2023-2025 (https://www.gov.scot/publications/scottish-healthcare-associated-infection-hcai-strategy-2023-2025/)).
- Healthcare Improvement Scotland's inspection regime assesses whether infection prevention and control is explicitly addressed in clinical governance processes, providing external assurance of compliance.
- This recommendation is implemented through the HAI Standards governance requirements and monitored through HIS inspections.
NHS Health Boards (Scotland) (Primary)
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R10
Accepted
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
- The Scottish Government published its response to the Vale of Leven Hospital Inquiry Report on 18 June 2015, accepting all 75 recommendations and establishing an Implementation Group chaired by the Chief Nursing Officer (Scottish Government Response, June 2015).
- The Scottish Government's response highlighted initiatives promoting person-centred care, including the 'What Matters to You?' approach which emphasises ensuring patients and families have sufficient knowledge about their health conditions and care.
- The Health and Social Care Standards (published June 2017, in use from April 2018) include Standard 1: 'I experience high quality care and support that is right for me' and Standard 2: 'I am fully involved in all decisions about my care and support,' which require that patients diagnosed with CDI are given information about their condition and prognosis (Health and Social Care Standards (https://www.gov.scot/publications/health-social-care-standards-support-life/)).
- The Charter of Patient Rights and Responsibilities (revised June 2022) sets out patients' right to information about their condition, treatment options, and care, including information about risks and infections.
- The NIPCM includes guidance on patient and family communication regarding healthcare-associated infections, supporting staff in providing clear, accurate information (National Infection Prevention and Control Manual for Scotland (https://www.nipcm.hps.scot.nhs.uk/about-the-manual/)).
NHS Health Boards (Scotland) (Primary)
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R11
Accepted
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
- The Scottish Government published its response to the Vale of Leven Hospital Inquiry Report on 18 June 2015, accepting all 75 recommendations and establishing an Implementation Group chaired by the Chief Nursing Officer (Scottish Government Response, June 2015).
- The Scottish Government's response highlighted initiatives promoting person-centred care, including the 'What Matters to You?' approach which emphasises ensuring patients and families have sufficient knowledge about their health conditions and care.
- The Health and Social Care Standards (published June 2017, in use from April 2018) include Standard 1: 'I experience high quality care and support that is right for me' and Standard 2: 'I am fully involved in all decisions about my care and support,' which require that patients and relatives are made aware that CDI can be life-threatening, particularly in the elderly (Health and Social Care Standards (https://www.gov.scot/publications/health-social-care-standards-support-life/)).
- The Charter of Patient Rights and Responsibilities (revised June 2022) sets out patients' right to information about their condition, treatment options, and care, including information about risks and infections.
- The NIPCM includes guidance on patient and family communication regarding healthcare-associated infections, supporting staff in providing clear, accurate information (National Infection Prevention and Control Manual for Scotland (https://www.nipcm.hps.scot.nhs.uk/about-the-manual/)).
NHS Health Boards (Scotland) (Primary)
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R12
Accepted
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
- The Scottish Government published its response to the Vale of Leven Hospital Inquiry Report on 18 June 2015, accepting all 75 recommendations and establishing an Implementation Group chaired by the Chief Nursing Officer (Scottish Government Response, June 2015).
- The Scottish Government's response highlighted initiatives promoting person-centred care, including the 'What Matters to You?' approach which emphasises ensuring patients and families have sufficient knowledge about their health conditions and care.
- The Health and Social Care Standards (published June 2017, in use from April 2018) include Standard 1: 'I experience high quality care and support that is right for me' and Standard 2: 'I am fully involved in all decisions about my care and support,' which require that patients and relatives are given clear advice on necessary infection control precautions (Health and Social Care Standards (https://www.gov.scot/publications/health-social-care-standards-support-life/)).
- The Charter of Patient Rights and Responsibilities (revised June 2022) sets out patients' right to information about their condition, treatment options, and care, including information about risks and infections.
- The NIPCM includes guidance on patient and family communication regarding healthcare-associated infections, supporting staff in providing clear, accurate information (National Infection Prevention and Control Manual for Scotland (https://www.nipcm.hps.scot.nhs.uk/about-the-manual/)).
NHS Health Boards (Scotland) (Primary)
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R13
Accepted
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
- The Scottish Government published its response to the Vale of Leven Hospital Inquiry Report on 18 June 2015, accepting all 75 recommendations and establishing an Implementation Group chaired by the Chief Nursing Officer (Scottish Government Response, June 2015).
- The Scottish Government's response highlighted the strengthened role of senior charge nurses through the Leading Better Care initiative, establishing clear professional accountability from ward level to board level.
- The Health and Care (Staffing) (Scotland) Act 2019 (provisions in force from 1 April 2024) requires NHS boards to establish clear lines of professional accountability and ensure clinical leaders have sufficient time allocated for management responsibilities (Health and Care (Staffing) (Scotland) Act 2019 (https://www.legislation.gov.uk/asp/2019/6)).
- The HAI Standards require the Infection Control Manager to report directly to the chief executive and the board, establishing a clear line of professional responsibility for infection prevention and control from ward to board level.
- Healthcare Improvement Scotland's Well-Led assessment considers whether there are clear and effective lines of professional responsibility throughout NHS organisations.
NHS Health Boards (Scotland) (Primary)
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R14
Accepted
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
- The Scottish Government published its response to the Vale of Leven Hospital Inquiry Report on 18 June 2015, accepting all 75 recommendations and establishing an Implementation Group chaired by the Chief Nursing Officer (Scottish Government Response, June 2015).
- The Scottish Government's response detailed professional standards for record-keeping, with the revised NMC Code (effective March 2015) requiring nurses and midwives to maintain clear, accurate, and contemporaneous patient records.
- The requirement that the nurse in charge audits compliance with record-keeping duties is embedded in the NMC Code's standards on record-keeping, which apply to all registered nurses and midwives practising in Scotland. The GMC's Good Medical Practice sets equivalent standards for doctors.
- The Health and Social Care Standards (published June 2017) include Standard 3: 'I have confidence in the people who support and care for me,' which encompasses professional standards including accurate record-keeping (Health and Social Care Standards (https://www.gov.scot/publications/health-social-care-standards-support-life/)).
- Healthcare Improvement Scotland assesses record-keeping quality as part of its inspection programme, and the Scottish Patient Safety Programme promotes standardised documentation practices including safety briefs and structured handovers.
NHS Health Boards (Scotland) (Primary)
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R15
Accepted
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
- The Scottish Government published its response to the Vale of Leven Hospital Inquiry Report on 18 June 2015, accepting all 75 recommendations and establishing an Implementation Group chaired by the Chief Nursing Officer (Scottish Government Response, June 2015).
- The Scottish Government's response detailed professional standards for record-keeping, with the revised NMC Code (effective March 2015) requiring nurses and midwives to maintain clear, accurate, and contemporaneous patient records.
- The requirement that nursing staff keep accurate records of observations for CDI patients is embedded in the NMC Code's standards on record-keeping, which apply to all registered nurses and midwives practising in Scotland. The GMC's Good Medical Practice sets equivalent standards for doctors.
- The Health and Social Care Standards (published June 2017) include Standard 3: 'I have confidence in the people who support and care for me,' which encompasses professional standards including accurate record-keeping (Health and Social Care Standards (https://www.gov.scot/publications/health-social-care-standards-support-life/)).
- Healthcare Improvement Scotland assesses record-keeping quality as part of its inspection programme, and the Scottish Patient Safety Programme promotes standardised documentation practices including safety briefs and structured handovers.
NHS Health Boards (Scotland) (Primary)
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R16
Accepted
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
- The Scottish Government published its response to the Vale of Leven Hospital Inquiry Report on 18 June 2015, accepting all 75 recommendations and establishing an Implementation Group chaired by the Chief Nursing Officer (Scottish Government Response, June 2015).
- The Scottish Government's response highlighted a robust HAI scrutiny regime across NHS Scotland, with the NIPCM providing clear guidance on outbreak identification and reporting procedures. The NIPCM requires that suspected outbreaks are reported to the Infection Control Team immediately (National Infection Prevention and Control Manual for Scotland (https://www.nipcm.hps.scot.nhs.uk/about-the-manual/)).
- National mandatory CDI surveillance in Scotland, started in 2006, requires NHS boards to report CDI cases through national surveillance systems. ARHAI Scotland (formerly Health Protection Scotland) provides national epidemiological analysis.
- The HAI Standards require clear escalation procedures for suspected outbreaks, with the Infection Control Manager responsible for coordinating the response and reporting to the board.
NHS Health Boards (Scotland) (Primary)
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R17
Accepted
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
- The Scottish Government published its response to the Vale of Leven Hospital Inquiry Report on 18 June 2015, accepting all 75 recommendations and establishing an Implementation Group chaired by the Chief Nursing Officer (Scottish Government Response, June 2015).
- The Scottish Government's response detailed the Standard Infection Control Precautions (SICPs), which include 'Patient Placement/Assessment for Infection Risk' as one of 10 core precautions. This establishes the principle that infection risk must be assessed before patient placement.
- The NIPCM provides detailed guidance on patient placement decisions during outbreaks, including the nurse in charge's role in managing admissions to affected wards or bays (National Infection Prevention and Control Manual for Scotland (https://www.nipcm.hps.scot.nhs.uk/about-the-manual/)).
- The Health and Care (Staffing) (Scotland) Act 2019 reinforces the clinical authority of nurses by ensuring registered nurses have sufficient seniority and authority to make clinical decisions including admission and placement decisions during infection outbreaks (Health and Care (Staffing) (Scotland) Act 2019 (https://www.legislation.gov.uk/asp/2019/6)).
NHS Health Boards (Scotland) (Primary)
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R18
Accepted
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
- The Scottish Government published its response to the Vale of Leven Hospital Inquiry Report on 18 June 2015, accepting all 75 recommendations and establishing an Implementation Group chaired by the Chief Nursing Officer (Scottish Government Response, June 2015).
- The Scottish Government's response detailed professional standards for record-keeping, with the revised NMC Code (effective March 2015) requiring nurses and midwives to maintain clear, accurate, and contemporaneous patient records.
- The requirement that an agreed system of care planning with documentation is in use in every ward is embedded in the NMC Code's standards on record-keeping, which apply to all registered nurses and midwives practising in Scotland. The GMC's Good Medical Practice sets equivalent standards for doctors.
- The Health and Social Care Standards (published June 2017) include Standard 3: 'I have confidence in the people who support and care for me,' which encompasses professional standards including accurate record-keeping (Health and Social Care Standards (https://www.gov.scot/publications/health-social-care-standards-support-life/)).
- Healthcare Improvement Scotland assesses record-keeping quality as part of its inspection programme, and the Scottish Patient Safety Programme promotes standardised documentation practices including safety briefs and structured handovers.
NHS Health Boards (Scotland) (Primary)
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R19
Accepted
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
- The Scottish Government published its response to the Vale of Leven Hospital Inquiry Report on 18 June 2015, accepting all 75 recommendations and establishing an Implementation Group chaired by the Chief Nursing Officer (Scottish Government Response, June 2015).
- The Scottish Government's response detailed professional standards for record-keeping, with the revised NMC Code (effective March 2015) requiring nurses and midwives to maintain clear, accurate, and contemporaneous patient records.
- The requirement that Infection Control Nurse instructions are recorded in patient notes is embedded in the NMC Code's standards on record-keeping, which apply to all registered nurses and midwives practising in Scotland. The GMC's Good Medical Practice sets equivalent standards for doctors.
- The Health and Social Care Standards (published June 2017) include Standard 3: 'I have confidence in the people who support and care for me,' which encompasses professional standards including accurate record-keeping (Health and Social Care Standards (https://www.gov.scot/publications/health-social-care-standards-support-life/)).
- Healthcare Improvement Scotland assesses record-keeping quality as part of its inspection programme, and the Scottish Patient Safety Programme promotes standardised documentation practices including safety briefs and structured handovers.
NHS Health Boards (Scotland) (Primary)
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R20
Accepted
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
- The Scottish Government published its response to the Vale of Leven Hospital Inquiry Report on 18 June 2015, accepting all 75 recommendations and establishing an Implementation Group chaired by the Chief Nursing Officer (Scottish Government Response, June 2015).
- The Scottish Government's response detailed professional standards for record-keeping, with the revised NMC Code (effective March 2015) requiring nurses and midwives to maintain clear, accurate, and contemporaneous patient records.
- The requirement that a proper stool record is kept for patients with suspected CDI is embedded in the NMC Code's standards on record-keeping, which apply to all registered nurses and midwives practising in Scotland. The GMC's Good Medical Practice sets equivalent standards for doctors.
- The Health and Social Care Standards (published June 2017) include Standard 3: 'I have confidence in the people who support and care for me,' which encompasses professional standards including accurate record-keeping (Health and Social Care Standards (https://www.gov.scot/publications/health-social-care-standards-support-life/)).
- Healthcare Improvement Scotland assesses record-keeping quality as part of its inspection programme, and the Scottish Patient Safety Programme promotes standardised documentation practices including safety briefs and structured handovers.
NHS Health Boards (Scotland) (Primary)
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R21
Accepted
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
- The Scottish Government published its response to the Vale of Leven Hospital Inquiry Report on 18 June 2015, accepting all 75 recommendations and establishing an Implementation Group chaired by the Chief Nursing Officer (Scottish Government Response, June 2015).
- The Scottish Government's response highlighted the Participation Standard, used by the Scottish Health Council to monitor how people are involved in their care, and the person-centred care initiatives including the 'What Matters to You?' approach.
- The Health and Social Care Standards (published June 2017) include Standard 2: 'I am fully involved in all decisions about my care and support,' which encompasses the right to access staff who can answer questions about care (Health and Social Care Standards (https://www.gov.scot/publications/health-social-care-standards-support-life/)).
- The Health and Care (Staffing) (Scotland) Act 2019 requires NHS boards to ensure staffing levels are appropriate for the care needs of patients, which includes having sufficient nursing staff available to communicate with patients and families (Health and Care (Staffing) (Scotland) Act 2019 (https://www.legislation.gov.uk/asp/2019/6)).
- The Charter of Patient Rights and Responsibilities (revised June 2022) sets out patients' right to be involved in their care and to have their views and those of their families heard.
NHS Health Boards (Scotland) (Primary)
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R22
Accepted
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
- The Scottish Government published its response to the Vale of Leven Hospital Inquiry Report on 18 June 2015, accepting all 75 recommendations and establishing an Implementation Group chaired by the Chief Nursing Officer (Scottish Government Response, June 2015).
- The Scottish Government's response detailed professional standards for record-keeping, with the revised NMC Code (effective March 2015) requiring nurses and midwives to maintain clear, accurate, and contemporaneous patient records.
- The requirement that discussions with relatives relevant to care are recorded is embedded in the NMC Code's standards on record-keeping, which apply to all registered nurses and midwives practising in Scotland. The GMC's Good Medical Practice sets equivalent standards for doctors.
- The Health and Social Care Standards (published June 2017) include Standard 3: 'I have confidence in the people who support and care for me,' which encompasses professional standards including accurate record-keeping (Health and Social Care Standards (https://www.gov.scot/publications/health-social-care-standards-support-life/)).
- Healthcare Improvement Scotland assesses record-keeping quality as part of its inspection programme, and the Scottish Patient Safety Programme promotes standardised documentation practices including safety briefs and structured handovers.
NHS Health Boards (Scotland) (Primary)
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R23
Accepted
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
- The Scottish Government published its response to the Vale of Leven Hospital Inquiry Report on 18 June 2015, accepting all 75 recommendations and establishing an Implementation Group chaired by the Chief Nursing Officer (Scottish Government Response, June 2015).
- The Scottish Government's response indicated that accredited education programmes for specialist and advanced practice roles, including Tissue Viability Nurses, are available through Scottish higher education institutions and NHS Education for Scotland (NES).
- NMC standards for post-registration education and practice require specialist nurses to hold or be working towards recognised specialist qualifications. The NMC's revalidation process (from April 2016) requires continuing professional development relevant to the nurse's scope of practice.
- NHS Education for Scotland provides a framework for specialist and advanced nursing practice development, including tissue viability, wound care, and related specialisms.
NHS Health Boards (Scotland) (Primary)
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R24
Accepted
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
- The Scottish Government published its response to the Vale of Leven Hospital Inquiry Report on 18 June 2015, accepting all 75 recommendations and establishing an Implementation Group chaired by the Chief Nursing Officer (Scottish Government Response, June 2015).
- The Scottish Government's response detailed professional standards for record-keeping, with the revised NMC Code (effective March 2015) requiring nurses and midwives to maintain clear, accurate, and contemporaneous patient records.
- The requirement that TVN instructions are clearly recorded in patient notes and care plans is embedded in the NMC Code's standards on record-keeping, which apply to all registered nurses and midwives practising in Scotland. The GMC's Good Medical Practice sets equivalent standards for doctors.
- The Health and Social Care Standards (published June 2017) include Standard 3: 'I have confidence in the people who support and care for me,' which encompasses professional standards including accurate record-keeping (Health and Social Care Standards (https://www.gov.scot/publications/health-social-care-standards-support-life/)).
- Healthcare Improvement Scotland assesses record-keeping quality as part of its inspection programme, and the Scottish Patient Safety Programme promotes standardised documentation practices including safety briefs and structured handovers.
NHS Health Boards (Scotland) (Primary)
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R25
Accepted
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
- The Scottish Government published its response to the Vale of Leven Hospital Inquiry Report on 18 June 2015, accepting all 75 recommendations and establishing an Implementation Group chaired by the Chief Nursing Officer (Scottish Government Response, June 2015).
- The Scottish Government's response stated that the prevention and management of pressure ulcers is a fundamental aspect of nursing practice. Healthcare Improvement Scotland (formerly NHS Quality Improvement Scotland) developed the Scottish approach to pressure ulcer prevention, including risk assessment tools.
- The Scottish Patient Safety Programme includes pressure ulcer prevention as one of its workstreams, with standardised risk assessment on admission as a Patient Safety Essential.
- The Health and Social Care Standards require that patients receive high-quality care appropriate to their needs, which includes assessment for pressure damage risk on admission (Health and Social Care Standards (https://www.gov.scot/publications/health-social-care-standards-support-life/)).
NHS Health Boards (Scotland) (Primary)
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R26
Accepted
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
- The Scottish Government published its response to the Vale of Leven Hospital Inquiry Report on 18 June 2015, accepting all 75 recommendations and establishing an Implementation Group chaired by the Chief Nursing Officer (Scottish Government Response, June 2015).
- The Scottish Government's response detailed professional standards for record-keeping, with the revised NMC Code (effective March 2015) requiring nurses and midwives to maintain clear, accurate, and contemporaneous patient records.
- The requirement that wound or pressure damage is documented in accordance with best practice is embedded in the NMC Code's standards on record-keeping, which apply to all registered nurses and midwives practising in Scotland. The GMC's Good Medical Practice sets equivalent standards for doctors.
- The Health and Social Care Standards (published June 2017) include Standard 3: 'I have confidence in the people who support and care for me,' which encompasses professional standards including accurate record-keeping (Health and Social Care Standards (https://www.gov.scot/publications/health-social-care-standards-support-life/)).
- Healthcare Improvement Scotland assesses record-keeping quality as part of its inspection programme, and the Scottish Patient Safety Programme promotes standardised documentation practices including safety briefs and structured handovers.
NHS Health Boards (Scotland) (Primary)
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R27
Accepted
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
- The Scottish Government published its response to the Vale of Leven Hospital Inquiry Report on 18 June 2015, accepting all 75 recommendations and establishing an Implementation Group chaired by the Chief Nursing Officer (Scottish Government Response, June 2015).
- The Scottish Government's response detailed professional standards for record-keeping, with the revised NMC Code (effective March 2015) requiring nurses and midwives to maintain clear, accurate, and contemporaneous patient records.
- The requirement that positional changes are recorded on turning charts is embedded in the NMC Code's standards on record-keeping, which apply to all registered nurses and midwives practising in Scotland. The GMC's Good Medical Practice sets equivalent standards for doctors.
- The Health and Social Care Standards (published June 2017) include Standard 3: 'I have confidence in the people who support and care for me,' which encompasses professional standards including accurate record-keeping (Health and Social Care Standards (https://www.gov.scot/publications/health-social-care-standards-support-life/)).
- Healthcare Improvement Scotland assesses record-keeping quality as part of its inspection programme, and the Scottish Patient Safety Programme promotes standardised documentation practices including safety briefs and structured handovers.
NHS Health Boards (Scotland) (Primary)
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R28
Accepted
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
- The Scottish Government published its response to the Vale of Leven Hospital Inquiry Report on 18 June 2015, accepting all 75 recommendations and establishing an Implementation Group chaired by the Chief Nursing Officer (Scottish Government Response, June 2015).
- The Scottish Government's response acknowledged criticisms of nutritional assessment and recording, and outlined measures to improve nutritional screening. NHS boards are expected to use recognised nutritional screening tools (such as MUST — Malnutrition Universal Screening Tool) on admission.
- The Food in Hospitals standards and the Health and Social Care Standards require that patients' nutritional needs are assessed on admission and regularly reviewed (Health and Social Care Standards (https://www.gov.scot/publications/health-social-care-standards-support-life/)).
- Healthcare Improvement Scotland includes nutrition and hydration assessment in its inspection framework.
NHS Health Boards (Scotland) (Primary)
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R29
Accepted
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
- The Scottish Government published its response to the Vale of Leven Hospital Inquiry Report on 18 June 2015, accepting all 75 recommendations and establishing an Implementation Group chaired by the Chief Nursing Officer (Scottish Government Response, June 2015).
- The Scottish Government's response addressed the need for appropriate equipment including weighing equipment, noting investment in NHS estates, assets, facilities, and equipment.
- The Health and Social Care Standards (published June 2017) include Standard 5: 'I experience a high quality environment if the organisation provides the premises,' which encompasses having appropriate equipment available for patient care (Health and Social Care Standards (https://www.gov.scot/publications/health-social-care-standards-support-life/)).
- The requirement to weigh patients on admission and regularly thereafter is embedded in nutritional screening protocols and nursing care standards across NHS Scotland.
NHS Health Boards (Scotland) (Primary)
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R30
Accepted
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
- The Scottish Government published its response to the Vale of Leven Hospital Inquiry Report on 18 June 2015, accepting all 75 recommendations and establishing an Implementation Group chaired by the Chief Nursing Officer (Scottish Government Response, June 2015).
- The Scottish Government's response detailed professional standards for record-keeping, with the revised NMC Code (effective March 2015) requiring nurses and midwives to maintain clear, accurate, and contemporaneous patient records.
- The requirement that fluid balance charts are completed accurately for patients requiring fluid monitoring is embedded in the NMC Code's standards on record-keeping, which apply to all registered nurses and midwives practising in Scotland. The GMC's Good Medical Practice sets equivalent standards for doctors.
- The Health and Social Care Standards (published June 2017) include Standard 3: 'I have confidence in the people who support and care for me,' which encompasses professional standards including accurate record-keeping (Health and Social Care Standards (https://www.gov.scot/publications/health-social-care-standards-support-life/)).
- Healthcare Improvement Scotland assesses record-keeping quality as part of its inspection programme, and the Scottish Patient Safety Programme promotes standardised documentation practices including safety briefs and structured handovers.
NHS Health Boards (Scotland) (Primary)
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R31
Accepted
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
- The Scottish Government published its response to the Vale of Leven Hospital Inquiry Report on 18 June 2015, accepting all 75 recommendations and establishing an Implementation Group chaired by the Chief Nursing Officer (Scottish Government Response, June 2015).
- The Scottish Government's response detailed the development and mandatory use of nursing and midwifery workload and workforce planning tools across all NHS boards, addressing the need for appropriate staffing and skills mix.
- The Health and Care (Staffing) (Scotland) Act 2019 (provisions in force from 1 April 2024) places a statutory duty on NHS boards to ensure both appropriate numbers of staff and appropriate types of professions. Boards must use the 'common staffing method' and report quarterly to Scottish Ministers on staffing (Health and Care (Staffing) (Scotland) Act 2019 (https://www.legislation.gov.uk/asp/2019/6)).
- This Act directly implements the principle that staffing and skills mix must be appropriate for each ward and reviewed in response to changes in activity and acuity.
NHS Health Boards (Scotland) (Primary)
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R32
Accepted
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
- The Scottish Government published its response to the Vale of Leven Hospital Inquiry Report on 18 June 2015, accepting all 75 recommendations and establishing an Implementation Group chaired by the Chief Nursing Officer (Scottish Government Response, June 2015).
- The NMC Code requires registered nurses and midwives to escalate concerns regarding patient safety or the level of care. The Scottish Government's response highlighted this professional duty and the need for clear escalation processes.
- The Health and Care (Staffing) (Scotland) Act 2019 (provisions in force from 1 April 2024) requires NHS boards to have procedures for the real-time identification of staffing risks and to address them promptly. It requires clinical leaders to be consulted on staffing decisions (Health and Care (Staffing) (Scotland) Act 2019 (https://www.legislation.gov.uk/asp/2019/6)).
- Scotland's whistleblowing standards (effective April 2021) provide additional protection for staff raising concerns about staffing levels, ensuring there is a clear and protected escalation route.
NHS Health Boards (Scotland) (Primary)
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R33
Accepted
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
- The Scottish Government published its response to the Vale of Leven Hospital Inquiry Report on 18 June 2015, accepting all 75 recommendations and establishing an Implementation Group chaired by the Chief Nursing Officer (Scottish Government Response, June 2015).
- The Scottish Government's response acknowledged the report's finding of 'poor complaint management by nursing teams' and the need for independent investigation of complaints about nursing practice.
- The Patient Rights (Scotland) Act 2011 established a complaints process for NHS Scotland, with the Scottish Public Services Ombudsman (SPSO) as the final stage of the complaints process. The NHS Scotland model complaints handling procedure sets out standards for complaint investigation.
- However, the specific recommendation that complaints about nursing practice on a ward should be investigated by an independent senior member of Nursing Management is a matter of local implementation within each NHS board. While the framework supports independent investigation, the consistency of implementation across all wards and boards is difficult to verify from published sources.
- Healthcare Improvement Scotland's inspection programme includes assessment of complaints handling, providing some external assurance.
NHS Health Boards (Scotland) (Primary)
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R34
Accepted
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
- The Scottish Government published its response to the Vale of Leven Hospital Inquiry Report on 18 June 2015, accepting all 75 recommendations and establishing an Implementation Group chaired by the Chief Nursing Officer (Scottish Government Response, June 2015).
- The Scottish Government's response outlined the HAI Taskforce's role in developing antimicrobial prescribing guidelines and the Controlling Antimicrobial Resistance in Scotland (CARS) programme, which monitors prescribing practices across NHS boards.
- The Scottish Antimicrobial Prescribing Group (SAPG) provides national leadership on antimicrobial stewardship, including guidelines, monitoring, and reporting. NHS board antimicrobial management teams drive implementation locally.
- The HCAI Strategy 2023-2025 includes antimicrobial resistance as a key priority, with surveillance and stewardship programmes ensuring that changes in antimicrobial policy are implemented without delay (Scottish HCAI Strategy 2023-2025 (https://www.gov.scot/publications/scottish-healthcare-associated-infection-hcai-strategy-2023-2025/)).
- ARHAI Scotland provides national surveillance data on antimicrobial resistance and prescribing patterns to support policy implementation.
NHS Health Boards (Scotland) (Primary)
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R35
Accepted
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
- The Scottish Government published its response to the Vale of Leven Hospital Inquiry Report on 18 June 2015, accepting all 75 recommendations and establishing an Implementation Group chaired by the Chief Nursing Officer (Scottish Government Response, June 2015).
- The Scottish Government's response outlined the HAI Taskforce's role in developing antimicrobial prescribing guidelines and the Controlling Antimicrobial Resistance in Scotland (CARS) programme, which monitors prescribing practices across NHS boards.
- The Scottish Antimicrobial Prescribing Group (SAPG) provides national leadership on antimicrobial stewardship, including guidelines, monitoring, and reporting. NHS board antimicrobial management teams drive implementation locally.
- The HCAI Strategy 2023-2025 includes antimicrobial resistance as a key priority, with surveillance and stewardship programmes ensuring that implementation of antibiotic prescribing guidance is monitored (Scottish HCAI Strategy 2023-2025 (https://www.gov.scot/publications/scottish-healthcare-associated-infection-hcai-strategy-2023-2025/)).
- ARHAI Scotland provides national surveillance data on antimicrobial resistance and prescribing patterns to support policy implementation.
Scottish Government (Primary)
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R36
Accepted
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
- The Scottish Government published its response to the Vale of Leven Hospital Inquiry Report on 18 June 2015, accepting all 75 recommendations and establishing an Implementation Group chaired by the Chief Nursing Officer (Scottish Government Response, June 2015).
- The Scottish Government's response stated a commitment to planning an NHS workforce that meets current and future care demands. The Health and Care (Staffing) (Scotland) Act 2019 (provisions in force from 1 April 2024) places statutory duties on NHS boards to ensure sufficient numbers of staff including medical staff (Health and Care (Staffing) (Scotland) Act 2019 (https://www.legislation.gov.uk/asp/2019/6)).
- Scottish Ministers are required under the Act to take steps to ensure sufficient numbers of registered nurses, midwives, and medical practitioners are available in Scotland.
- NHS Education for Scotland manages medical training and workforce planning for Scotland's medical workforce.
NHS Health Boards (Scotland) (Primary)
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R37
Accepted
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 published its response to the Vale of Leven Hospital Inquiry Report on 18 June 2015, accepting all 75 recommendations and establishing an Implementation Group chaired by the Chief Nursing Officer (Scottish Government Response, June 2015).
- Scotland's Health Protection Scotland (now ARHAI Scotland) developed clinical guidance for CDI management, including the requirement for prompt senior medical assessment and timely commencement of specific antibiotic therapy.
- The NIPCM includes guidance on the clinical management of CDI, and the Scottish Antimicrobial Prescribing Group provides prescribing guidance for CDI treatment (National Infection Prevention and Control Manual for Scotland (https://www.nipcm.hps.scot.nhs.uk/about-the-manual/)).
- NHS board antimicrobial management teams are responsible for ensuring CDI treatment protocols are followed, with surveillance data monitoring treatment timeliness and outcomes.
NHS Health Boards (Scotland) (Primary)
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R38
Accepted
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 published its response to the Vale of Leven Hospital Inquiry Report on 18 June 2015, accepting all 75 recommendations and establishing an Implementation Group chaired by the Chief Nursing Officer (Scottish Government Response, June 2015).
- The Scottish Government's response directly addressed this recommendation, emphasising that clear, accurate, and legible patient records by doctors are integral to good patient care.
- The GMC's Good Medical Practice requires doctors to maintain clear, accurate, and legible records that include all relevant clinical findings, decisions, and information given to patients. GMC revalidation (from December 2012) requires doctors to demonstrate compliance with these record-keeping standards.
- The Health and Social Care Standards (published June 2017) encompass professional record-keeping expectations (Health and Social Care Standards (https://www.gov.scot/publications/health-social-care-standards-support-life/)).
NHS Health Boards (Scotland) (Primary)
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R39
Accepted
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 published its response to the Vale of Leven Hospital Inquiry Report on 18 June 2015, accepting all 75 recommendations and establishing an Implementation Group chaired by the Chief Nursing Officer (Scottish Government Response, June 2015).
- The Scottish Government's response noted the clinically and ethically challenging nature of DNAR decisions. Scotland has adopted the 'Do Not Attempt Cardiopulmonary Resuscitation' (DNACPR) integrated adult policy, developed collaboratively by NHS boards, which provides a standardised approach across Scotland.
- The policy requires that DNACPR decisions are made by senior clinicians in consultation with patients and families, clearly documented in patient records, and regularly reviewed.
- The Certification of Death (Scotland) Act 2011 and associated guidance reinforce the importance of accurate recording of end-of-life decisions in patient care records.
NHS Health Boards (Scotland) (Primary)
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R40
Accepted
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 published its response to the Vale of Leven Hospital Inquiry Report on 18 June 2015, accepting all 75 recommendations and establishing an Implementation Group chaired by the Chief Nursing Officer (Scottish Government Response, June 2015).
- The Scottish Government's response outlined the HAI Taskforce's role in developing antimicrobial prescribing guidelines and the Controlling Antimicrobial Resistance in Scotland (CARS) programme, which monitors prescribing practices across NHS boards.
- The Scottish Antimicrobial Prescribing Group (SAPG) provides national leadership on antimicrobial stewardship, including guidelines, monitoring, and reporting. NHS board antimicrobial management teams drive implementation locally.
- The HCAI Strategy 2023-2025 includes antimicrobial resistance as a key priority, with surveillance and stewardship programmes ensuring that prudent antibiotic prescribing is adhered to and monitored (Scottish HCAI Strategy 2023-2025 (https://www.gov.scot/publications/scottish-healthcare-associated-infection-hcai-strategy-2023-2025/)).
- ARHAI Scotland provides national surveillance data on antimicrobial resistance and prescribing patterns to support policy implementation.
NHS Health Boards (Scotland) (Primary)
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R41
Accepted
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 published its response to the Vale of Leven Hospital Inquiry Report on 18 June 2015, accepting all 75 recommendations and establishing an Implementation Group chaired by the Chief Nursing Officer (Scottish Government Response, June 2015).
- The Scottish Government's response outlined the HAI Taskforce's role in developing antimicrobial prescribing guidelines and the Controlling Antimicrobial Resistance in Scotland (CARS) programme, which monitors prescribing practices across NHS boards.
- The Scottish Antimicrobial Prescribing Group (SAPG) provides national leadership on antimicrobial stewardship, including guidelines, monitoring, and reporting. NHS board antimicrobial management teams drive implementation locally.
- The HCAI Strategy 2023-2025 includes antimicrobial resistance as a key priority, with surveillance and stewardship programmes ensuring that there is no unnecessary delay in processing lab specimens and commencing treatment (Scottish HCAI Strategy 2023-2025 (https://www.gov.scot/publications/scottish-healthcare-associated-infection-hcai-strategy-2023-2025/)).
- ARHAI Scotland provides national surveillance data on antimicrobial resistance and prescribing patterns to support policy implementation.
NHS Health Boards (Scotland) (Primary)
View Details
R42
Accepted
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 published its response to the Vale of Leven Hospital Inquiry Report on 18 June 2015, accepting all 75 recommendations and establishing an Implementation Group chaired by the Chief Nursing Officer (Scottish Government Response, June 2015).
- The Scottish Government's response confirmed that the HAI Taskforce delivery plan included education and training frameworks to ensure all those working in a healthcare setting have mandatory IPC training including CDI on appointment. The Cleanliness Champions Programme, introduced in September 2003, has been completed by over 18,000 NHS Scotland staff.
- NHS Education for Scotland (NES) provides national education programmes for IPC, including specialist training for Infection Control Nurses and Doctors, mandatory induction training for all healthcare workers, and continuing professional development resources.
- The HCAI Strategy 2023-2025 includes workforce education as a priority, with ARHAI Scotland supporting training and competency development across NHS boards (Scottish HCAI Strategy 2023-2025 (https://www.gov.scot/publications/scottish-healthcare-associated-infection-hcai-strategy-2023-2025/)).
- Regulatory bodies (NMC, GMC) require continuing professional development as a condition of registration, reinforced through revalidation processes.
NHS Health Boards (Scotland) (Primary)
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R43
Accepted
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 published its response to the Vale of Leven Hospital Inquiry Report on 18 June 2015, accepting all 75 recommendations and establishing an Implementation Group chaired by the Chief Nursing Officer (Scottish Government Response, June 2015).
- The Scottish Government's response confirmed that the HAI Taskforce delivery plan included education and training frameworks to ensure Infection Control Nurses and Doctors have regular IPC training with records kept. The Cleanliness Champions Programme, introduced in September 2003, has been completed by over 18,000 NHS Scotland staff.
- NHS Education for Scotland (NES) provides national education programmes for IPC, including specialist training for Infection Control Nurses and Doctors, mandatory induction training for all healthcare workers, and continuing professional development resources.
- The HCAI Strategy 2023-2025 includes workforce education as a priority, with ARHAI Scotland supporting training and competency development across NHS boards (Scottish HCAI Strategy 2023-2025 (https://www.gov.scot/publications/scottish-healthcare-associated-infection-hcai-strategy-2023-2025/)).
- Regulatory bodies (NMC, GMC) require continuing professional development as a condition of registration, reinforced through revalidation processes.
NHS Health Boards (Scotland) (Primary)
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R44
Accepted
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 published its response to the Vale of Leven Hospital Inquiry Report on 18 June 2015, accepting all 75 recommendations and establishing an Implementation Group chaired by the Chief Nursing Officer (Scottish Government Response, June 2015).
- The Scottish Government's response confirmed that the HAI Taskforce delivery plan included education and training frameworks to ensure performance appraisals of IPC staff take place at least annually. The Cleanliness Champions Programme, introduced in September 2003, has been completed by over 18,000 NHS Scotland staff.
- NHS Education for Scotland (NES) provides national education programmes for IPC, including specialist training for Infection Control Nurses and Doctors, mandatory induction training for all healthcare workers, and continuing professional development resources.
- The HCAI Strategy 2023-2025 includes workforce education as a priority, with ARHAI Scotland supporting training and competency development across NHS boards (Scottish HCAI Strategy 2023-2025 (https://www.gov.scot/publications/scottish-healthcare-associated-infection-hcai-strategy-2023-2025/)).
- Regulatory bodies (NMC, GMC) require continuing professional development as a condition of registration, reinforced through revalidation processes.
NHS Health Boards (Scotland) (Primary)
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R45
Accepted
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 published its response to the Vale of Leven Hospital Inquiry Report on 18 June 2015, accepting all 75 recommendations and establishing an Implementation Group chaired by the Chief Nursing Officer (Scottish Government Response, June 2015).
- The Scottish Government's response detailed the specific responsibilities of the Infection Control Manager (ICM), including overall responsibility for coordinating prevention and control of infection. The response confirmed that this should be specified in job descriptions.
- The HAI Standards require clear role specifications for ICMs, including defined responsibilities within the organisation's governance structure.
NHS Health Boards (Scotland) (Primary)
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R46
Accepted
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 published its response to the Vale of Leven Hospital Inquiry Report on 18 June 2015, accepting all 75 recommendations and establishing an Implementation Group chaired by the Chief Nursing Officer (Scottish Government Response, June 2015).
- The Scottish Government's response confirmed that the ICM has overall responsibility for coordinating prevention and control of infection throughout the organisation, with direct responsibility for the IPC service and its staff.
- The HAI Standards define the ICM role as having operational management of the Infection Prevention and Control Team, with accountability for service delivery and staff management.
NHS Health Boards (Scotland) (Primary)
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R47
Accepted
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 published its response to the Vale of Leven Hospital Inquiry Report on 18 June 2015, accepting all 75 recommendations and establishing an Implementation Group chaired by the Chief Nursing Officer (Scottish Government Response, June 2015).
- The Scottish Government's response explicitly stated that the ICM is accountable directly to the chief executive and the board. The HAI Standards require this direct reporting line, ensuring IPC concerns reach the highest level of governance without being filtered through intermediate management.
- Healthcare Improvement Scotland monitors whether this direct reporting line is in place through its inspection programme.
NHS Health Boards (Scotland) (Primary)
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R48
Accepted
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 published its response to the Vale of Leven Hospital Inquiry Report on 18 June 2015, accepting all 75 recommendations and establishing an Implementation Group chaired by the Chief Nursing Officer (Scottish Government Response, June 2015).
- The Scottish Government's response specified that the ICM is responsible for producing an annual report on the state of HAI, decontamination, and cleaning in the organisation, to be presented to the Board.
- The HAI Standards require regular board-level reporting on HAI metrics, with the ICM responsible for ensuring the board has current information on infection prevention and control performance.
NHS Health Boards (Scotland) (Primary)
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R49
Accepted
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
- The Scottish Government published its response to the Vale of Leven Hospital Inquiry Report on 18 June 2015, accepting all 75 recommendations and establishing an Implementation Group chaired by the Chief Nursing Officer (Scottish Government Response, June 2015).
- The Scottish Government's response indicated that work was underway since 2014/15 to ensure ICMs have direct management responsibility for the IPC service. National guidance on the ICM role was to be re-issued to reflect this requirement.
- The HAI Standards and the HCAI Strategy 2023-2025 reinforce the ICM's management responsibilities, with Healthcare Improvement Scotland monitoring compliance (Scottish HCAI Strategy 2023-2025 (https://www.gov.scot/publications/scottish-healthcare-associated-infection-hcai-strategy-2023-2025/)).
Scottish Government (Primary)
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R50
Accepted
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
- The Scottish Government published its response to the Vale of Leven Hospital Inquiry Report on 18 June 2015, accepting all 75 recommendations and establishing an Implementation Group chaired by the Chief Nursing Officer (Scottish Government Response, June 2015).
- The Scottish Government's response discussed general workforce planning, including the use of nursing and midwifery workload and workforce planning tools. However, the specific requirement for 24-hour IPC cover seven days a week with contingency plans for leave and sickness was addressed at a general level rather than with a specific commitment.
- The Health and Care (Staffing) (Scotland) Act 2019 requires appropriate staffing levels at all times, which implicitly includes IPC staffing. However, 24/7 specialist IPC cover is a resource-intensive requirement that smaller boards may struggle to maintain consistently (Health and Care (Staffing) (Scotland) Act 2019 (https://www.legislation.gov.uk/asp/2019/6)).
- The HAI Standards require NHS boards to have arrangements for IPC advice and support, but the extent to which 24/7 specialist IPC cover is consistently provided across all 14 NHS boards is not centrally reported.
NHS Health Boards (Scotland) (Primary)
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R51
Accepted
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
- The Scottish Government published its response to the Vale of Leven Hospital Inquiry Report on 18 June 2015, accepting all 75 recommendations and establishing an Implementation Group chaired by the Chief Nursing Officer (Scottish Government Response, June 2015).
- The Scottish Government's response highlighted the role of the national HAI Taskforce in coordinating actions across NHS Scotland, working with local IPC teams. The HAI Standards require each NHS board to have a functioning Infection Control Team with clear lines of communication and regular meetings.
- The HCAI Strategy 2023-2025 reinforces the requirement for effective IPC team working at national and board levels (Scottish HCAI Strategy 2023-2025 (https://www.gov.scot/publications/scottish-healthcare-associated-infection-hcai-strategy-2023-2025/)).
NHS Health Boards (Scotland) (Primary)
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R52
Accepted
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
- The Scottish Government published its response to the Vale of Leven Hospital Inquiry Report on 18 June 2015, accepting all 75 recommendations and establishing an Implementation Group chaired by the Chief Nursing Officer (Scottish Government Response, June 2015).
- The Scottish Government's response detailed national and local surveillance data collection, including mandatory CDI surveillance (started 2006 for patients aged 65+, extended April 2009 to all aged 15+). The LDP standard requires CDI rates of 0.32 or less per 1,000 total occupied bed days.
- Scotland achieved a CDI rate of 0.27 per 1,000 occupied bed days in the year ending December 2018, meeting the target with a decreasing year-on-year trend of 7.5% between 2014 and 2018.
- The requirement that adherence to IPC policies including CDI policies is audited at least annually is addressed through national surveillance systems operated by ARHAI Scotland (formerly Health Protection Scotland) and local audit requirements within the HAI Standards.
- The HCAI Strategy 2023-2025 maintains surveillance and reporting as core elements of Scotland's approach to HAI reduction (Scottish HCAI Strategy 2023-2025 (https://www.gov.scot/publications/scottish-healthcare-associated-infection-hcai-strategy-2023-2025/)).
NHS Health Boards (Scotland) (Primary)
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R53
Accepted
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
- The Scottish Government published its response to the Vale of Leven Hospital Inquiry Report on 18 June 2015, accepting all 75 recommendations and establishing an Implementation Group chaired by the Chief Nursing Officer (Scottish Government Response, June 2015).
- The Scottish Government's response detailed national and local surveillance data collection, including mandatory CDI surveillance (started 2006 for patients aged 65+, extended April 2009 to all aged 15+). The LDP standard requires CDI rates of 0.32 or less per 1,000 total occupied bed days.
- Scotland achieved a CDI rate of 0.27 per 1,000 occupied bed days in the year ending December 2018, meeting the target with a decreasing year-on-year trend of 7.5% between 2014 and 2018.
- The requirement that surveillance systems are fit for purpose and provide real-time outbreak information is addressed through national surveillance systems operated by ARHAI Scotland (formerly Health Protection Scotland) and local audit requirements within the HAI Standards.
- The HCAI Strategy 2023-2025 maintains surveillance and reporting as core elements of Scotland's approach to HAI reduction (Scottish HCAI Strategy 2023-2025 (https://www.gov.scot/publications/scottish-healthcare-associated-infection-hcai-strategy-2023-2025/)).
NHS Health Boards (Scotland) (Primary)
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R54
Accepted
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
- The Scottish Government published its response to the Vale of Leven Hospital Inquiry Report on 18 June 2015, accepting all 75 recommendations and establishing an Implementation Group chaired by the Chief Nursing Officer (Scottish Government Response, June 2015).
- The Scottish Government's response confirmed that the HAI Taskforce delivery plan included education and training frameworks to ensure users of surveillance systems are properly trained. The Cleanliness Champions Programme, introduced in September 2003, has been completed by over 18,000 NHS Scotland staff.
- NHS Education for Scotland (NES) provides national education programmes for IPC, including specialist training for Infection Control Nurses and Doctors, mandatory induction training for all healthcare workers, and continuing professional development resources.
- The HCAI Strategy 2023-2025 includes workforce education as a priority, with ARHAI Scotland supporting training and competency development across NHS boards (Scottish HCAI Strategy 2023-2025 (https://www.gov.scot/publications/scottish-healthcare-associated-infection-hcai-strategy-2023-2025/)).
- Regulatory bodies (NMC, GMC) require continuing professional development as a condition of registration, reinforced through revalidation processes.
NHS Health Boards (Scotland) (Primary)
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R55
Accepted
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
- The Scottish Government published its response to the Vale of Leven Hospital Inquiry Report on 18 June 2015, accepting all 75 recommendations and establishing an Implementation Group chaired by the Chief Nursing Officer (Scottish Government Response, June 2015).
- The Scottish Government's response detailed national and local surveillance data collection, including mandatory CDI surveillance (started 2006 for patients aged 65+, extended April 2009 to all aged 15+). The LDP standard requires CDI rates of 0.32 or less per 1,000 total occupied bed days.
- Scotland achieved a CDI rate of 0.27 per 1,000 occupied bed days in the year ending December 2018, meeting the target with a decreasing year-on-year trend of 7.5% between 2014 and 2018.
- The requirement that CDI numbers and rates are reported through each level of the organisation to the Board is addressed through national surveillance systems operated by ARHAI Scotland (formerly Health Protection Scotland) and local audit requirements within the HAI Standards.
- The HCAI Strategy 2023-2025 maintains surveillance and reporting as core elements of Scotland's approach to HAI reduction (Scottish HCAI Strategy 2023-2025 (https://www.gov.scot/publications/scottish-healthcare-associated-infection-hcai-strategy-2023-2025/)).
NHS Health Boards (Scotland) (Primary)
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R56
Accepted
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
- The Scottish Government published its response to the Vale of Leven Hospital Inquiry Report on 18 June 2015, accepting all 75 recommendations and establishing an Implementation Group chaired by the Chief Nursing Officer (Scottish Government Response, June 2015).
- The HAI Standards require NHS boards to maintain IPC governance structures with regular meetings, appropriate reporting lines, and lay involvement. The requirement that IPC groups meet at regular intervals with appropriate upward reporting is embedded in the governance framework monitored by Healthcare Improvement Scotland.
- The Scottish Government's response outlined the requirement for IPC governance at all organisational levels, from ward-based teams through to the board, with the ICM responsible for ensuring effective governance structures are in place.
- The NHS Reform (Scotland) Act 2004 requires NHS boards to involve patients and public in decision-making, which includes representation on governance committees including those dealing with IPC.
NHS Health Boards (Scotland) (Primary)
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R57
Accepted
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
- The Scottish Government published its response to the Vale of Leven Hospital Inquiry Report on 18 June 2015, accepting all 75 recommendations and establishing an Implementation Group chaired by the Chief Nursing Officer (Scottish Government Response, June 2015).
- The HAI Standards require NHS boards to maintain IPC governance structures with regular meetings, appropriate reporting lines, and lay involvement. The requirement that minutes and reports from IPC committees are reported upward through the hierarchy is embedded in the governance framework monitored by Healthcare Improvement Scotland.
- The Scottish Government's response outlined the requirement for IPC governance at all organisational levels, from ward-based teams through to the board, with the ICM responsible for ensuring effective governance structures are in place.
- The NHS Reform (Scotland) Act 2004 requires NHS boards to involve patients and public in decision-making, which includes representation on governance committees including those dealing with IPC.
NHS Health Boards (Scotland) (Primary)
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R58
Accepted
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
- The Scottish Government published its response to the Vale of Leven Hospital Inquiry Report on 18 June 2015, accepting all 75 recommendations and establishing an Implementation Group chaired by the Chief Nursing Officer (Scottish Government Response, June 2015).
- The HAI Standards require NHS boards to maintain IPC governance structures with regular meetings, appropriate reporting lines, and lay involvement. The requirement that there is lay representation at Board IPC committee level is embedded in the governance framework monitored by Healthcare Improvement Scotland.
- The Scottish Government's response outlined the requirement for IPC governance at all organisational levels, from ward-based teams through to the board, with the ICM responsible for ensuring effective governance structures are in place.
- The NHS Reform (Scotland) Act 2004 requires NHS boards to involve patients and public in decision-making, which includes representation on governance committees including those dealing with IPC.
NHS Health Boards (Scotland) (Primary)
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R59
Accepted
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
- The Scottish Government published its response to the Vale of Leven Hospital Inquiry Report on 18 June 2015, accepting all 75 recommendations and establishing an Implementation Group chaired by the Chief Nursing Officer (Scottish Government Response, June 2015).
- The HAI Standards require NHS boards to maintain IPC governance structures with regular meetings, appropriate reporting lines, and lay involvement. The requirement that attendance at IPC committee meetings is treated as a priority is embedded in the governance framework monitored by Healthcare Improvement Scotland.
- The Scottish Government's response outlined the requirement for IPC governance at all organisational levels, from ward-based teams through to the board, with the ICM responsible for ensuring effective governance structures are in place.
- The NHS Reform (Scotland) Act 2004 requires NHS boards to involve patients and public in decision-making, which includes representation on governance committees including those dealing with IPC.
NHS Health Boards (Scotland) (Primary)
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R60
Accepted
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
- The Scottish Government published its response to the Vale of Leven Hospital Inquiry Report on 18 June 2015, accepting all 75 recommendations and establishing an Implementation Group chaired by the Chief Nursing Officer (Scottish Government Response, June 2015).
- The Scottish Government's response confirmed that the HAI Taskforce delivery plan included education and training frameworks to ensure programmes such as Cleanliness Champions are implemented without delay. The Cleanliness Champions Programme, introduced in September 2003, has been completed by over 18,000 NHS Scotland staff.
- NHS Education for Scotland (NES) provides national education programmes for IPC, including specialist training for Infection Control Nurses and Doctors, mandatory induction training for all healthcare workers, and continuing professional development resources.
- The HCAI Strategy 2023-2025 includes workforce education as a priority, with ARHAI Scotland supporting training and competency development across NHS boards (Scottish HCAI Strategy 2023-2025 (https://www.gov.scot/publications/scottish-healthcare-associated-infection-hcai-strategy-2023-2025/)).
- Regulatory bodies (NMC, GMC) require continuing professional development as a condition of registration, reinforced through revalidation processes.
NHS Health Boards (Scotland) (Primary)
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R61
Accepted
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
- The Scottish Government published its response to the Vale of Leven Hospital Inquiry Report on 18 June 2015, accepting all 75 recommendations and establishing an Implementation Group chaired by the Chief Nursing Officer (Scottish Government Response, June 2015).
- Healthcare Improvement Scotland (HIS) conducts both announced and unannounced inspections of NHS facilities, including assessment of IPC standards. The HEI function within HIS was established in April 2009 and has conducted at least 30 unannounced inspections annually.
- The Scottish Government's response confirmed the role of HIS in providing independent scrutiny of IPC practice, with lay assessors participating in inspections.
- The recommendation for unannounced inspections by senior IPC staff with lay representation is implemented through the HIS inspection programme.
NHS Health Boards (Scotland) (Primary)
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R62
Accepted
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
- The Scottish Government published its response to the Vale of Leven Hospital Inquiry Report on 18 June 2015, accepting all 75 recommendations and establishing an Implementation Group chaired by the Chief Nursing Officer (Scottish Government Response, June 2015).
- The Scottish Government's response detailed the 10 Patient Safety Essentials, which include leadership walk-rounds. These involve leaders, including executive and non-executive board members accompanied by IPC staff, visiting clinical areas to assess safety and IPC compliance.
- The Scottish Patient Safety Programme (SPSP), launched in 2008, promotes leadership walk-rounds as a core safety practice across NHS Scotland. Since launch, hospital mortality in Scotland has fallen by 16.5%.
- The recommendation for weekly visits by senior managers accompanied by IPC staff is addressed through the SPSP framework, though the frequency of visits varies by board.
NHS Health Boards (Scotland) (Primary)
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R63
Accepted
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
- The Scottish Government published its response to the Vale of Leven Hospital Inquiry Report on 18 June 2015, accepting all 75 recommendations and establishing an Implementation Group chaired by the Chief Nursing Officer (Scottish Government Response, June 2015).
- Scottish Government policy requires all planned new-build hospitals to provide 100% single-room accommodation, significantly improving capacity for patient isolation. For refurbished accommodation, a minimum of 50% single rooms is required (Scottish Health Planning Note 04-01, October 2010).
- The NIPCM includes detailed guidance on patient isolation for CDI and other infections, including when isolation is required and how to manage it effectively (National Infection Prevention and Control Manual for Scotland (https://www.nipcm.hps.scot.nhs.uk/about-the-manual/)).
- The significant increase in single-room capacity across NHS Scotland directly supports the effective isolation of patients with CDI.
NHS Health Boards (Scotland) (Primary)
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R64
Accepted
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
- The Scottish Government published its response to the Vale of Leven Hospital Inquiry Report on 18 June 2015, accepting all 75 recommendations and establishing an Implementation Group chaired by the Chief Nursing Officer (Scottish Government Response, June 2015).
- The 100% single-room policy for new-build hospitals significantly reduces the need for cohorting as a substitute for isolation. The NIPCM provides guidance that cohorting should only be used when single-room isolation is not available, confirming it should not be the default approach (National Infection Prevention and Control Manual for Scotland (https://www.nipcm.hps.scot.nhs.uk/about-the-manual/)).
- The ongoing programme of hospital building and refurbishment in Scotland, with the single-room requirement, progressively reduces reliance on cohorting across the NHS Scotland estate.
NHS Health Boards (Scotland) (Primary)
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R65
Accepted
Isolation for infectious diarrhoea
Recommendation

Health Boards should ensure that appropriate steps are taken to isolate patients with potentially infectious diarrhoea.

Published evidence summary
- The Scottish Government published its response to the Vale of Leven Hospital Inquiry Report on 18 June 2015, accepting all 75 recommendations and establishing an Implementation Group chaired by the Chief Nursing Officer (Scottish Government Response, June 2015).
- The NIPCM includes Standard Infection Control Precautions (SICPs), of which 'Patient Placement/Assessment for Infection Risk' is one of 10 core precautions. This requires that patients with potentially infectious diarrhoea are appropriately isolated (National Infection Prevention and Control Manual for Scotland (https://www.nipcm.hps.scot.nhs.uk/about-the-manual/)).
- The single-room policy for new-build hospitals supports the availability of isolation facilities for patients with infectious diarrhoea.
NHS Health Boards (Scotland) (Primary)
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R66
Accepted
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
- The Scottish Government published its response to the Vale of Leven Hospital Inquiry Report on 18 June 2015, accepting all 75 recommendations and establishing an Implementation Group chaired by the Chief Nursing Officer (Scottish Government Response, June 2015).
- The Scottish Government's response highlighted the revised NHSScotland National Cleaning Services Specification and its monitoring framework, enabling NHS boards to assess and improve cleaning standards.
- The Health and Social Care Standards (published June 2017) include Standard 5: 'I experience a high quality environment,' which encompasses building maintenance, cleanliness, and fitness for purpose (Health and Social Care Standards (https://www.gov.scot/publications/health-social-care-standards-support-life/)).
- Healthcare Improvement Scotland inspects the healthcare environment including maintenance and cleanliness as part of its HAI inspection programme.
NHS Health Boards (Scotland) (Primary)
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R67
Accepted
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
- The Scottish Government published its response to the Vale of Leven Hospital Inquiry Report on 18 June 2015, accepting all 75 recommendations and establishing an Implementation Group chaired by the Chief Nursing Officer (Scottish Government Response, June 2015).
- The Scottish Government's response confirmed that the HAI Taskforce delivery plan included education and training frameworks to ensure Link Nurses have specific training for that role. The Cleanliness Champions Programme, introduced in September 2003, has been completed by over 18,000 NHS Scotland staff.
- NHS Education for Scotland (NES) provides national education programmes for IPC, including specialist training for Infection Control Nurses and Doctors, mandatory induction training for all healthcare workers, and continuing professional development resources.
- The HCAI Strategy 2023-2025 includes workforce education as a priority, with ARHAI Scotland supporting training and competency development across NHS boards (Scottish HCAI Strategy 2023-2025 (https://www.gov.scot/publications/scottish-healthcare-associated-infection-hcai-strategy-2023-2025/)).
- Regulatory bodies (NMC, GMC) require continuing professional development as a condition of registration, reinforced through revalidation processes.
NHS Health Boards (Scotland) (Primary)
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R68
Accepted
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
- The Scottish Government published its response to the Vale of Leven Hospital Inquiry Report on 18 June 2015, accepting all 75 recommendations and establishing an Implementation Group chaired by the Chief Nursing Officer (Scottish Government Response, June 2015).
- The Certification of Death (Scotland) Act 2011 (key sections in force from 13 May 2015) reformed death certification in Scotland. The Act established the Death Certification Review Service (DCRS), which randomly reviews approximately 12% of all death certificates for accuracy (Certification of Death (Scotland) Act 2011 (https://www.legislation.gov.uk/asp/2011/11/contents)).
- Medical reviewers, employed by Healthcare Improvement Scotland, scrutinise sampled death certificates. The system is designed to improve the accuracy and reliability of death certification without imposing fees on bereaved families.
- While the Act does not mandate that the consultant in charge certifies the cause of death, the DCRS review process provides quality assurance that encourages senior medical involvement in certification.
NHS Health Boards (Scotland) (Primary)
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R69
Accepted
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
- The Scottish Government published its response to the Vale of Leven Hospital Inquiry Report on 18 June 2015, accepting all 75 recommendations and establishing an Implementation Group chaired by the Chief Nursing Officer (Scottish Government Response, June 2015).
- The Scottish Government's response emphasised person-centred care, including ensuring families receive clear explanations when CDI is a cause of or contributes to death. The 'What Matters to You?' approach supports staff in communicating sensitively with bereaved families.
- The Health and Social Care Standards require that patients and families have sufficient knowledge and understanding of their health care, including information about outcomes and causes of death (Health and Social Care Standards (https://www.gov.scot/publications/health-social-care-standards-support-life/)).
- The Charter of Patient Rights and Responsibilities (revised June 2022) supports the right to clear information and explanation about care and outcomes.
NHS Health Boards (Scotland) (Primary)
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R70
Accepted
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
- The Scottish Government published its response to the Vale of Leven Hospital Inquiry Report on 18 June 2015, accepting all 75 recommendations and establishing an Implementation Group chaired by the Chief Nursing Officer (Scottish Government Response, June 2015).
- The Scottish Government wrote to the Crown Office and Procurator Fiscal Service (COPFS) requesting action on this recommendation. COPFS publishes guidance on the reporting of deaths to the Procurator Fiscal, including guidance for medical practitioners (COPFS, Reporting Deaths).
- However, the specific recommendation was that COPFS should review its death reporting guidance regularly and at least every two years. There is limited published evidence of a formal, regular two-yearly review cycle for COPFS death reporting guidance since the Vale of Leven inquiry.
- COPFS death reports decreased by 30% between 2010/11 (13,090) and 2014/15 (9,155), while Fatal Accident Inquiries more than doubled in 2014/15.
COPFS (Primary)
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R71
Accepted
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
- The Scottish Government published its response to the Vale of Leven Hospital Inquiry Report on 18 June 2015, accepting all 75 recommendations and establishing an Implementation Group chaired by the Chief Nursing Officer (Scottish Government Response, June 2015).
- The Scottish Government's response noted the call for better national monitoring of HAI-related mortality. National and local CDI surveillance data is collected by ARHAI Scotland (formerly Health Protection Scotland), and CDI rates are reported through national surveillance systems.
- However, the specific recommendation for a national agency to undertake routine monitoring of deaths specifically related to CDI has not been clearly implemented as a distinct, named function. CDI-related mortality data is captured within broader surveillance and mortality statistics, but whether a dedicated monitoring programme exists specifically for CDI deaths is not clearly evidenced from published sources.
- The HCAI Strategy 2023-2025 addresses HAI surveillance broadly but does not specifically reference a dedicated CDI mortality monitoring programme (Scottish HCAI Strategy 2023-2025 (https://www.gov.scot/publications/scottish-healthcare-associated-infection-hcai-strategy-2023-2025/)).
Scottish Government (Primary)
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R72
Accepted
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
- The Scottish Government published its response to the Vale of Leven Hospital Inquiry Report on 18 June 2015, accepting all 75 recommendations and establishing an Implementation Group chaired by the Chief Nursing Officer (Scottish Government Response, June 2015).
- The Scottish Government's response discussed feedback, complaints, and governance arrangements but did not provide a clear commitment to ensuring non-executive board members or internal audit representatives participate in all internal investigations.
- The 'Governance for Quality Healthcare in Scotland' framework sets out governance standards for NHS boards, and HIS inspects governance arrangements. However, the specific requirement for non-executive or audit participation in internal investigations is a matter of local board policy.
- This recommendation has been partially addressed through governance frameworks, but there is limited evidence of a national standard mandating non-executive involvement in all internal investigations.
NHS Health Boards (Scotland) (Primary)
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R73
Accepted
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
- The Scottish Government published its response to the Vale of Leven Hospital Inquiry Report on 18 June 2015, accepting all 75 recommendations and establishing an Implementation Group chaired by the Chief Nursing Officer (Scottish Government Response, June 2015).
- The Scottish Government's response highlighted the requirement for NHS boards to ensure that Outbreak Control Team reports provide sufficient detail for proper audit. The HCAI Strategy 2023-2025 includes learning and improvement as core elements, with ARHAI Scotland facilitating the sharing of lessons across NHS boards (Scottish HCAI Strategy 2023-2025 (https://www.gov.scot/publications/scottish-healthcare-associated-infection-hcai-strategy-2023-2025/)).
- Healthcare Improvement Scotland's role includes reviewing and disseminating findings from inquiries, reports, and international evidence to support continuous improvement in patient safety across NHS Scotland.
- The Scottish Patient Safety Programme provides a framework for embedding learning from incidents, reports, and inspections into routine practice.
NHS Health Boards (Scotland) (Primary)
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R74
Accepted
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
- The Scottish Government published its response to the Vale of Leven Hospital Inquiry Report on 18 June 2015, accepting all 75 recommendations and establishing an Implementation Group chaired by the Chief Nursing Officer (Scottish Government Response, June 2015).
- The Scottish Government's response highlighted the requirement for NHS boards to ensure that reports from the UK and other jurisdictions on IPC and patient safety are reviewed promptly. The HCAI Strategy 2023-2025 includes learning and improvement as core elements, with ARHAI Scotland facilitating the sharing of lessons across NHS boards (Scottish HCAI Strategy 2023-2025 (https://www.gov.scot/publications/scottish-healthcare-associated-infection-hcai-strategy-2023-2025/)).
- Healthcare Improvement Scotland's role includes reviewing and disseminating findings from inquiries, reports, and international evidence to support continuous improvement in patient safety across NHS Scotland.
- The Scottish Patient Safety Programme provides a framework for embedding learning from incidents, reports, and inspections into routine practice.
Scottish Government (Primary)
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R75
Accepted
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
- The Scottish Government published its response to the Vale of Leven Hospital Inquiry Report on 18 June 2015, accepting all 75 recommendations and establishing an Implementation Group chaired by the Chief Nursing Officer (Scottish Government Response, June 2015).
- The Scottish Government's response highlighted the requirement for NHS boards to ensure that NHS boards review relevant reports to determine lessons learned and implement measures. The HCAI Strategy 2023-2025 includes learning and improvement as core elements, with ARHAI Scotland facilitating the sharing of lessons across NHS boards (Scottish HCAI Strategy 2023-2025 (https://www.gov.scot/publications/scottish-healthcare-associated-infection-hcai-strategy-2023-2025/)).
- Healthcare Improvement Scotland's role includes reviewing and disseminating findings from inquiries, reports, and international evidence to support continuous improvement in patient safety across NHS Scotland.
- The Scottish Patient Safety Programme provides a framework for embedding learning from incidents, reports, and inspections into routine practice.
NHS Health Boards (Scotland) (Primary)
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