Vale of Leven Hospital Inquiry
CompletedVale of Leven Inquiry
The Vale of Leven Hospital Inquiry investigated the occurrence of Clostridium difficile infection at the Vale of Leven Hospital from 1 January 2007 onwards, particularly between 1 December 2007 and 1 June 2008, and the deaths associated with that infection. The inquiry identified 34 deaths where C. difficile infection was implicated and found serious deficiencies in infection control practices. The report made 75 recommendations on infection prevention and control, leadership, and patient safety.
5 years, 3 months
Duration
Parliamentary Activity 5 Click to expand
since Jun 2016
05 Sep 2023
Early Day Motion
Red Ramp Events and the Golden Friendship Club
Martin Docherty-Hughes (Scottish National Party)
18 Apr 2023
Martin Docherty-Hughes (Scottish National Party)
Early Day Motion
50 years of West Dunbartonshire Citizens Advice Bureau
Martin Docherty-Hughes (Scottish National Party)
08 Sep 2021
Martin Docherty-Hughes (Scottish National Party)
Early Day Motion
20TH ANNIVERSARY OF THE MURDER OF CAROLINE GLACHAN
Martin Docherty-Hughes (Scottish National Party)
05 Sep 2016
Martin Docherty-Hughes (Scottish National Party)
Early Day Motion
QUEEN'S AWARD FOR VOLUNTARY SERVICE TO THE VALE OF LEVEN AUTISM AND …
Martin Docherty-Hughes (Scottish National Party)
15 Jun 2016
Martin Docherty-Hughes (Scottish National Party)
Reports (1) Click to expand
| Title | Volume | Publication Date | Recs | Links |
|---|---|---|---|---|
| The Vale of Leven Hospital Inquiry Report | Final Report | 24 Nov 2014 | 75 |
Timeline (3) Click to expand
01 May 2009
Inquiry Announced
01 Nov 2009
Inquiry Established
24 Nov 2014
Final Report Published
Recommendations (75)
HEI ward closure powers
Recommendation
Scottish Government should ensure that the Healthcare Environment Inspectorate (HEI) has the power to close a ward to new admissions if the HEI concludes that there is a real risk to the safety of patients.
Published evidence summary
The Healthcare Environment Inspectorate (HEI) has held statutory powers to restrict admissions to wards where patient safety is at risk since April 2009, under the NHS (Scotland) Act 1978 as amended (Healthcare Improvement Scotland, 2024; Scottish Government, 2015). HEI has conducted over 200 inspections since its inception, with at least 30 annually, mostly unannounced (Healthcare Improvement Scotland, 2024). The Scottish Government accepted this recommendation in its June 2015 response, noting the existing powers.
Scottish Government
(Primary)
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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 accepted this recommendation, publishing Revised Healthcare Associated Infection (HAI) Standards in February 2015 and establishing a robust HAI scrutiny regime. Successive national strategies have been published, including the AMR/HAI 5-Year Strategic Framework 2016-2021 and the HCAI Strategy 2023-2025, with a new five-year IPC strategy for 2025-2030 in development (Scottish Government progress update, 19 Jun 2023). By June 2024, all 30 first-phase deliverables of the HCAI Strategy had been progressed, with six identified as complete, and the National Infection Prevention and Control Manual (NIPCM) and Care Home IPCM are established and operational (Scottish Government HAI Progress Report, 01 Mar 2025).
Scottish Government
(Primary)
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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
ARHAI Scotland and NHS National Services Scotland reported in July 2022 that the National Infection Prevention and Control Manual (NIPCM) was relaunched by the Chief Nursing Officer and subsequently updated in 2023 to reflect post-COVID transition. The NIPCM serves as the authoritative, evidence-based guidance for infection prevention and control across NHS Scotland, requiring Health Boards to promptly review and update their local policies in response to its changes. The Scottish Government accepted this recommendation in June 2015, stating that NHS boards must adhere to revised Healthcare Associated Infection (HAI) Standards and the NIPCM.
NHS Health Boards (Scotland)
(Primary)
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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 national Healthcare Associated Infection (HAI) Taskforce was restructured into a smaller, more focused group that works with local teams and existing structures in NHS boards to provide leadership and expert advice (Scottish Government response, 2015-06-18). The Scottish Government developed the AMR/HAI 5-Year Strategic Framework 2016-2021, which included local implementation structures within Health Boards (Scottish Government, 2016-10-18). This framework was succeeded by the HCAI Strategy 2023-2025, which includes local governance arrangements, and local implementation is monitored through the national governance framework (Scottish Government, 2016-10-18).
Scottish Government
(Primary)
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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's response (18 June 2015) committed to ensuring that uncertainty over the future of any hospital or service is resolved without undue delay, noting that the issue at Vale of Leven Hospital affected morale and staffing. The response outlined broader health policy initiatives, such as the 2020 Vision and the integration of health and social care, and an intention to develop a longer-term plan for health and social care. However, no specific legislative or structural reforms were explicitly introduced to prevent delays in resolving hospital future uncertainty, and no further published evidence on specific mechanisms for this resolution has been identified since 2015.
Scottish Government
(Primary)
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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 accepted this recommendation in 2015, outlining its intention to develop a longer-term plan for health and social care, including the integration of services to ensure seamless, joined-up care (Scottish Government's Response, 2015). The National Clinical Strategy for Scotland (2016) and subsequent workforce planning frameworks address service change management; however, the evidence does not detail specific enforcement mechanisms for ensuring clear and effective plans for continuity of safe patient care during major service changes. No further published evidence has been identified since 2016.
Scottish Government
(Primary)
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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's 2015 response indicated that due diligence requirements for NHS reorganisations are addressed through existing governance frameworks and the Code of Corporate Governance for NHS Scotland. However, no specific new legislation or mechanism mandating a dedicated due diligence process, including risk assessment, for major structural reorganisations has been publicly confirmed since the initial response in 2015.
NHS Health Boards (Scotland)
(Primary)
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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 accepted this recommendation in 2015, committing to ensuring effective management structures during NHS reorganisations. The government's response (18 June 2015) highlighted ongoing work in leadership and management development and the reinforcement of existing governance frameworks. However, no specific new requirements were introduced to address this recommendation, and no further published evidence has been identified since 2015.
NHS Health Boards (Scotland)
(Primary)
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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 accepted this recommendation in 2015. Healthcare Improvement Scotland (HIS) published its Infection Prevention and Control (IPC) Standards in May 2022, which include Standard 1 (Leadership and Governance) requiring IPC to be explicitly considered at all clinical governance levels from ward to Board (Healthcare Improvement Scotland, 1 May 2022). However, a Scottish Government Oversight Board report (1 March 2021) identified "significant failings in governance" regarding IPC at Queen Elizabeth University Hospital within NHS Greater Glasgow and Clyde, indicating challenges in the practical application of these governance requirements.
NHS Health Boards (Scotland)
(Primary)
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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 Charter of Patient Rights and Responsibilities was revised in June 2022 under the Patient Rights (Scotland) Act 2011, strengthening patient rights to information (Scottish Government, 2022). The statutory Duty of Candour, established under the Health (Tobacco Nicotine etc. and Care) (Scotland) Act 2016 and detailed in the Duty of Candour Procedure (Scotland) Regulations 2018, requires health organisations to inform patients about incidents and their condition (Scottish Government, 2022). Non-statutory guidance for the Duty of Candour was revised in March 2025 (Scottish Government, 2022).
NHS Health Boards (Scotland)
(Primary)
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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
Patient rights were strengthened through the Charter of Patient Rights, revised in June 2022, and the statutory Duty of Candour, ensuring patients and families have the right to be informed about conditions and risks, including healthcare-associated infections (Scottish Government, 2022). The Duty of Candour specifically requires organisations to inform affected persons and provide an account when a notifiable safety incident occurs (Scottish Government, 2022).
NHS Health Boards (Scotland)
(Primary)
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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 Duty of Candour and the Patient Rights Charter have strengthened requirements for clear communication with patients and families regarding their health conditions (Scottish Government, 2022). Healthcare Improvement Scotland's (HIS) Infection Prevention and Control (IPC) Standards (2022) include Standard 3, which specifically mandates effective communication systems for IPC with patients, families, and staff across all health and social care settings (Healthcare Improvement Scotland, 2022).
NHS Health Boards (Scotland)
(Primary)
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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 commissioned the Excellence in Care (EiC) framework specifically in response to the Vale of Leven Inquiry, which is now operational in every NHS board with dedicated leads and a strategy published in June 2022 (Healthcare Improvement Scotland, 2025). The EiC framework, which includes the CAIR Dashboard for nursing and midwifery care quality metrics, aims to enhance professional responsibility from the ward level (Healthcare Improvement Scotland, 2025). However, a Scottish Government Oversight Board report in March 2021 noted significant governance failings and IPC issues at NHS GGC between 2015-2019, suggesting that systemic issues persisted in the same health board despite the inquiry's recommendations.
NHS Health Boards (Scotland)
(Primary)
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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 Excellence in Care (EiC) framework, commissioned in response to the inquiry, now includes the CAIR Dashboard which monitors nursing care quality metrics, including record-keeping standards, across all NHS Scotland boards (Healthcare Improvement Scotland, 2025). The CAIR Dashboard, produced by Public Health Scotland, provides standardised metrics for nursing and midwifery care quality, with every board having dedicated EiC and Digital Leads (Healthcare Improvement Scotland, 2025).
NHS Health Boards (Scotland)
(Primary)
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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 Excellence in Care (EiC) framework, established in response to the inquiry, incorporates patient observation recording standards (Healthcare Improvement Scotland, 2025). The CAIR Dashboard, part of the EiC framework, monitors compliance with nursing documentation requirements, including patient observations, across all NHS Scotland boards (Healthcare Improvement Scotland, 2025).
NHS Health Boards (Scotland)
(Primary)
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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
Healthcare Improvement Scotland's (HIS) Infection Prevention and Control (IPC) Standards (2022), specifically Standard 4, mandate the reporting of suspected outbreaks to IPC teams (Healthcare Improvement Scotland, 2022). The National Infection Prevention and Control Manual (NIPCM), introduced in January 2012, provides detailed guidance including mandatory *Clostridioides difficile* infection (CDI) outbreak reporting protocols (Scottish Government, 2015; Healthcare Improvement Scotland, 2022). National mandatory CDI surveillance has been operational since 2006 for patients aged 65+ and since April 2009 for all patients aged 15+ (Healthcare Improvement Scotland, 2022).
NHS Health Boards (Scotland)
(Primary)
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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's Standard Infection Control Precautions (SICP), the National Infection Prevention and Control Manual (NIPCM), and the Excellence in Care (EiC) framework address ward admission control during infection risk (Scottish Government, 2015; Healthcare Improvement Scotland, 2025). Healthcare Improvement Scotland's (HIS) IPC Standards (2022) Standard 4 covers ward-level infection management, including admission decisions, with HEI inspections assessing compliance (Healthcare Improvement Scotland, 2025). However, operational compliance with these national standards is noted to vary by board (Healthcare Improvement Scotland, 2025).
NHS Health Boards (Scotland)
(Primary)
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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 Excellence in Care (EiC) framework, commissioned specifically in response to the Vale of Leven Inquiry, directly addresses care planning systems within NHS Scotland (Healthcare Improvement Scotland, 2025). The CAIR Dashboard, part of the EiC framework, monitors the fundamentals of care, including compliance with care planning documentation, across all NHS boards (Healthcare Improvement Scotland, 2025).
NHS Health Boards (Scotland)
(Primary)
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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 accepted this recommendation, referencing the revised NMC code for nurses and GMC requirements for doctors, which mandate recording of instructions in patient notes. Healthcare Improvement Scotland's Excellence in Care framework monitors nursing documentation standards, including the recording of Infection Control Nurse instructions, with compliance tracked via the CAIR Dashboard (Healthcare Improvement Scotland progress update, 01 Jan 2025).
NHS Health Boards (Scotland)
(Primary)
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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 accepted this recommendation, citing the revised NMC code for nurses which requires accurate record-keeping, including identifying risks and problems such as C. difficile diarrhoea. The National Infection Prevention and Control Manual (NIPCM) includes specific guidance on CDI patient management, encompassing stool monitoring (Healthcare Improvement Scotland progress update, 01 Jan 2025). The Excellence in Care framework monitors fundamentals of care documentation standards, with ward-level compliance tracked via the CAIR Dashboard and Healthcare Environment Inspectorate (HEI) inspections (Healthcare Improvement Scotland progress update, 01 Jan 2025).
NHS Health Boards (Scotland)
(Primary)
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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 accepted this recommendation, highlighting the Scottish Health Council's Participation Standard and the Person-centred Health and Care Collaborative. The Duty of Candour Procedure (Scotland) Regulations 2018 (https://www.legislation.gov.uk/ssi/2018/179/contents/made) require organisations to inform affected persons, including family members, and the Patient Rights Charter was revised in 2022 to strengthen communication requirements with relatives (Scottish Government progress update, 01 Jun 2022). The Excellence in Care framework includes Communication as a foundational requirement, informed by the experiences of Vale of Leven families (Scottish Government progress update, 01 Jun 2022).
NHS Health Boards (Scotland)
(Primary)
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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 accepted this recommendation, referencing the revised NMC code for nurses and the Scottish Government's Records Management: NHS code of practice (Scotland) for accurate record-keeping. The Duty of Candour requires documentation of communications with patients and families regarding safety incidents, ensuring discussions relevant to continuing care are recorded (Scottish Government progress update, 01 Jun 2022). The Excellence in Care CAIR Dashboard monitors communication standards, ensuring statutory duties for documenting discussions with relatives are followed up (Scottish Government progress update, 01 Jun 2022).
NHS Health Boards (Scotland)
(Primary)
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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 accepted this recommendation, stating that accredited education programmes for specialist roles, including Tissue Viability Nurses (TVNs), are available through universities and funded by NHS boards. NHS Education for Scotland (NES) provides specialist training pathways, including tissue viability nursing, through the Turas Learn platform (Healthcare Improvement Scotland progress update, 01 Jan 2025). However, Healthcare Improvement Scotland noted that no specific national TVN qualification requirement has been mandated (Healthcare Improvement Scotland progress update, 01 Jan 2025).
NHS Health Boards (Scotland)
(Primary)
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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 accepted this recommendation, referencing the revised NMC code for nurses and GMC requirements for doctors, which mandate clear, accurate, and timely record-keeping of instructions and actions. Healthcare Improvement Scotland's Excellence in Care framework monitors care documentation, including specialist nursing instructions from TVNs (Healthcare Improvement Scotland progress update, 01 Jan 2025). The CAIR Dashboard tracks documentation compliance across all boards (Healthcare Improvement Scotland progress update, 01 Jan 2025).
NHS Health Boards (Scotland)
(Primary)
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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 accepted this recommendation, noting that Healthcare Improvement Scotland published a Best Practice Statement on the Prevention and Management of Pressure Ulcers in 2009 and that the national Tissue Viability Programme commenced in the same year. The Excellence in Care framework includes pressure damage risk assessment as a fundamental aspect of care, and the Waterlow Score or an equivalent risk assessment on admission is part of the national nursing quality framework (Healthcare Improvement Scotland progress update, 01 Jan 2025). Compliance with pressure damage prevention measures is monitored across all boards via the CAIR Dashboard (Healthcare Improvement Scotland progress update, 01 Jan 2025).
NHS Health Boards (Scotland)
(Primary)
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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 accepted this recommendation, referencing the revised NMC code for nurses and GMC requirements for doctors, which mandate clear and accurate record-keeping. Healthcare Improvement Scotland's Best Practice Statement on pressure ulcers (2009) provides guidance on wound documentation. The Excellence in Care CAIR Dashboard monitors wound documentation standards as part of fundamentals of care metrics, and national wound care guidance is available (Healthcare Improvement Scotland progress update, 01 Jan 2025).
NHS Health Boards (Scotland)
(Primary)
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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 accepted this recommendation, referencing the revised NMC code for nurses which provides specific guidance requiring clear, accurate, and timely record-keeping for care such as positional changes. Healthcare Improvement Scotland's Excellence in Care framework monitors nursing documentation, including positional change records (Healthcare Improvement Scotland progress update, 01 Jan 2025). The CAIR Dashboard tracks fundamentals of care compliance, confirming that turning charts or equivalent documentation are addressed through national nursing quality metrics (Healthcare Improvement Scotland progress update, 01 Jan 2025).
NHS Health Boards (Scotland)
(Primary)
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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
Healthcare Improvement Scotland (HIS) reported in January 2025 that the Excellence in Care CAIR Dashboard includes nutritional screening measures, with nutritional screening on admission monitored as part of fundamentals of care. HIS has also published National Food Fluid and Nutritional Care Standards. The Scottish Government accepted this recommendation in June 2015.
NHS Health Boards (Scotland)
(Primary)
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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
Healthcare Improvement Scotland (HIS) reported in January 2025 that the Excellence in Care framework includes nutritional standards that require patient weighing on admission. The CAIR Dashboard monitors nutrition measures, including weighing compliance, across all NHS boards. The Scottish Government's June 2015 response detailed over £400 million investment in NHS infrastructure between 2014-2016, with increased funding for routine maintenance and equipment replacement for NHS boards.
NHS Health Boards (Scotland)
(Primary)
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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
Healthcare Improvement Scotland (HIS) reported in January 2025 that the Excellence in Care CAIR Dashboard monitors fluid balance chart completion as a nationally tracked metric within the fundamentals of care across all NHS Scotland boards. The Scottish Government accepted this recommendation in June 2015, referencing the revised NMC code which requires nurses to maintain clear, accurate, and timely records, including signing, dating, and timing entries for critical care elements.
NHS Health Boards (Scotland)
(Primary)
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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 Health and Care (Staffing) (Scotland) Act 2019 came into force on 1 April 2024, establishing a statutory basis for appropriate staffing, including the Common Staffing Method with mandatory staffing level tools for adult inpatient wards. This legislation requires clinical and care staffing levels to be reviewed in response to increases in patient acuity. The Scottish Government accepted this recommendation in June 2015, detailing the development and mandatory use of nursing and midwifery workload and workforce planning tools.
NHS Health Boards (Scotland)
(Primary)
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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 Health and Care (Staffing) (Scotland) Act 2019, which came into force in April 2024, includes statutory requirements for escalation when staffing falls below safe levels and mandates that employers have processes for reporting and escalating staffing concerns. The Scottish Government accepted this recommendation in June 2015, referencing the NMC code's requirement for nurses to escalate concerns and highlighting a national whistleblowing policy with a dedicated freephone service.
NHS Health Boards (Scotland)
(Primary)
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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's June 2015 response acknowledged 'poor complaint management by nursing teams' and stated that the NHS Scotland Complaints Handling Procedure was revised and standardised across all health boards. However, the specific requirement for an independent senior member of Nursing Management to investigate nursing complaints was addressed through general complaints reform rather than a dedicated mechanism. No further published evidence has been identified since 2015.
NHS Health Boards (Scotland)
(Primary)
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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 Antimicrobial Prescribing Group (SAPG), operational since 2008, provides comprehensive guidance on antimicrobial stewardship across hospital, community, dental, and care home settings, including specific CDI-related prescribing guidance. SAPG publishes prescribing data through Public Health Scotland and has demonstrated year-on-year reductions in inappropriate prescribing. The Scottish Government accepted this recommendation in June 2015, outlining the development of guidelines and the establishment of the Controlling Antimicrobial Resistance in Scotland Group.
NHS Health Boards (Scotland)
(Primary)
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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 Antimicrobial Prescribing Group (SAPG) monitors the implementation of antibiotic prescribing policies nationally, with prescribing data published through Public Health Scotland. By January 2015, SAPG reported a 5.4% decrease in primary care antibiotic prescriptions and a 12.7% reduction in antibiotics that increase C. difficile risk. Continuous monitoring is conducted through a national surveillance system, and SAPG celebrated 15 years of operation in 2023.
Scottish Government
(Primary)
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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 Health and Care (Staffing) (Scotland) Act 2019, which came into force in April 2024, covers medical staffing levels alongside nursing and applies the Common Staffing Method to all clinical staffing decisions. This legislation provides a statutory basis for ensuring medical staffing is sufficient for safe, high-quality care. The Scottish Government accepted this recommendation in June 2015, noting a commitment to workforce planning and a significant increase in NHS consultant numbers between 2006 and 2014.
NHS Health Boards (Scotland)
(Primary)
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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
Scotland's Health Protection Network published C. diff guidance, revised in 2014, which outlines roles, responsibilities, and best practice on antimicrobial treatment (Scottish Government response, 2015-06-18). NHS boards are supported with tools such as a C. diff testing protocol, a severe case investigation tool, and a C. diff 'care bundle' (Scottish Government response, 2015-06-18). The National Infection Prevention and Control Manual (NIPCM) provides detailed clinical guidance on CDI assessment and treatment, including the requirement for senior medical assessment, and the Scottish Antimicrobial Prescribing Group (SAPG) addresses timely CDI-specific antibiotic therapy (ARHAI Scotland / NIPCM, 2022-07-11).
NHS Health Boards (Scotland)
(Primary)
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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 General Medical Council (GMC) requires doctors to maintain clear, accurate, and legible records, made at the time of events or as soon as possible (Scottish Government response, 2015-06-18). The Scottish Government developed its 'Records Management: NHS code of practice (Scotland)', updated in 2012 (Scottish Government response, 2015-06-18). Healthcare Improvement Scotland's 'Excellence in Care framework' and NHS Scotland governance standards address medical record keeping requirements, with national standards for clinical documentation in place (Healthcare Improvement Scotland, 2025-01-01). Electronic health record systems are being rolled out across NHS Scotland, which addresses legibility concerns (Healthcare Improvement Scotland, 2025-01-01).
NHS Health Boards (Scotland)
(Primary)
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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 the 'Do Not Attempt Cardiopulmonary Resuscitation (DNACPR) Integrated Adult Policy' in 2016, which provides a standardised national approach to DNACPR decisions across NHS Scotland (Scottish Government, 2015-06-18). Subsequent updates to this policy have addressed communication requirements with patients and families regarding DNACPR decisions (Scottish Government, 2015-06-18).
NHS Health Boards (Scotland)
(Primary)
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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 HAI Taskforce develops guidelines, including an antimicrobial prescribing policy for Scotland, and the Scottish Management of Antimicrobial Resistance Action Plan 2014-18 was implemented (Scottish Government response, 2015-06-18). The Controlling Antimicrobial Resistance in Scotland Group was established to oversee activity and produce outcome measures, while the Scottish Antimicrobial Prescribing Group (SAPG) supports implementation (Scottish Government response, 2015-06-18). SAPG provides comprehensive prudent antibiotic prescribing guidance, has published hospital and community antimicrobial stewardship good practice recommendations, and continues national monitoring of prescribing trends (SAPG, 2025-01-01).
NHS Health Boards (Scotland)
(Primary)
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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
NHS board antimicrobial management teams (AMTs) promote antimicrobial policies and educate clinical staff on antimicrobial stewardship (Scottish Government response, 2015-06-18). eHealth initiatives, including the TrakCare patient management system and an online clinical portal, enable electronic storage and sharing of images, results, and diagnoses, enhancing timely processing and reporting (Scottish Government response, 2015-06-18). The National Infection Prevention and Control Manual (NIPCM) provides guidance on laboratory specimen handling and CDI testing, and a national surveillance system requires timely reporting of positive results, with CDI testing turnaround times monitored as national surveillance quality indicators (ARHAI Scotland / NIPCM, 2022-07-11).
NHS Health Boards (Scotland)
(Primary)
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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 HAI Taskforce delivery plan promoted a strategy for appropriate education and training for all healthcare workers, and the Cleanliness Champions Programme trained over 18,000 staff (Scottish Government response, 2015-06-18). The Scottish Infection Prevention and Control Education Pathway (SIPCEP) now provides mandatory IPC training, integrating the Cleanliness Champions Programme, and an IPC Zone is available on the Turas Learn platform (NHS Education for Scotland, 2025-01-01). Healthcare Improvement Scotland published new Infection Prevention and Control Standards in May 2022, which apply to all health and adult social care settings in Scotland, with HIS IPC Standard 2 (Staff Education) requiring mandatory IPC training on appointment and regularly thereafter (Healthcare Improvement Scotland, 2022-05-01).
NHS Health Boards (Scotland)
(Primary)
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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 HAI Taskforce delivery plan included an education framework for specialists in infection prevention and control, with accredited education programmes available for specialist and advanced practice roles for nurses, often funded by NHS boards (Scottish Government response, 2015-06-18). The Scottish Infection Prevention and Control Education Pathway (SIPCEP) includes a specialist IPC training pathway (NHS Education for Scotland, 2025-01-01). The Infection Prevention Workforce Strategic Plan 2022-2024 addresses IPC specialist career development and continuing education, and a new IPC Specialist Career Framework is currently being developed (NHS Education for Scotland, 2025-01-01).
NHS Health Boards (Scotland)
(Primary)
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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
Registered health professionals are regulated by bodies like the NMC and GMC, which set professional standards, and revalidation for doctors, which began in December 2012, is supported by a system of appraisal (Scottish Government response, 2015-06-18). Revised appraisal guidance for NHS Scotland was developed, and training is provided for appraisers and appraisees (Scottish Government response, 2015-06-18). Healthcare Improvement Scotland's (HIS) IPC Standards (2022) Standard 1 (Leadership and Governance) includes requirements for IPC staff performance management, and the Infection Prevention Workforce Strategic Plan 2022-2024 addresses workforce development (Healthcare Improvement Scotland, 2022-05-01).
NHS Health Boards (Scotland)
(Primary)
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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 response detailed the specific responsibilities of the Infection Control Manager (ICM), including overall responsibility for coordinating infection prevention and control throughout the NHS board area and delivering the board-approved infection prevention and control programme (Scottish Government response, 2015-06-18). Healthcare Improvement Scotland's (HIS) IPC Standards (2022) Standard 1 (Leadership and Governance) specifies requirements for IPC management roles and responsibilities within health boards, providing a national framework for IPC management accountability, including job description requirements (Healthcare Improvement Scotland, 2022-05-01).
NHS Health Boards (Scotland)
(Primary)
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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's response (18 June 2015) outlined the Infection Control Manager's (ICM) overall responsibility for coordinating infection prevention and control and delivering the board-approved programme. Healthcare Improvement Scotland's (HIS) IPC Standards (2022) Standard 1 further addresses the IPC management structure and direct responsibility for IPC services, providing a national framework for this role.
NHS Health Boards (Scotland)
(Primary)
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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's response (18 June 2015) stated that the Infection Control Manager (ICM) is directly accountable to the chief executive and the board, with efforts ongoing since 2014/15 to reinforce this. Healthcare Improvement Scotland's (HIS) IPC Standards (2022) Standard 1 (Leadership and Governance) addresses these reporting structures and board-level oversight requirements. However, a Scottish Government Oversight Board report (1 March 2021) identified that within NHS GGC, key IPC information, including DMA Canyon water reports, was not escalated to senior management and the Board, indicating a failure in effective implementation in that instance.
NHS Health Boards (Scotland)
(Primary)
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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's response (18 June 2015) specified that the Infection Control Manager (ICM) is responsible for producing an annual public report on the state of healthcare-associated infections (HAI), decontamination, and cleaning, and is directly accountable to the chief executive and the board for this reporting. Healthcare Improvement Scotland's (HIS) IPC Standards (2022) Standard 1 addresses IPC reporting to boards, while Standard 4 (Assurance and Monitoring) mandates systematic monitoring and reporting of HAI data to board level, with HIS inspections monitoring compliance.
NHS Health Boards (Scotland)
(Primary)
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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's response (18 June 2015) indicated ongoing work since 2014/15 to reinforce the Infection Control Manager's (ICM) direct accountability to the board and their overall responsibility for infection prevention and control. National guidance on the ICM role has been reissued through the Infection Prevention Workforce Strategic Plan 2022-2024 and Healthcare Improvement Scotland's (HIS) IPC Standards (2022) Standard 1, which provides a framework for ICM responsibilities. Additionally, a new IPC Specialist Career Framework is under development, and ARHAI Scotland provides national coordination.
Scottish Government
(Primary)
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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
Healthcare Improvement Scotland's (HIS) IPC Standards (2022) explicitly address the requirements for 24-hour, seven-day-a-week infection prevention and control (IPC) cover. Additionally, the Infection Prevention Workforce Strategic Plan 2022-2024 addresses workforce planning for IPC services, including the necessary contingency arrangements for leave and sickness absence. The Scottish Government's response (18 June 2015) discussed general workforce planning but did not detail specific provisions for 24/7 IPC cover.
NHS Health Boards (Scotland)
(Primary)
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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
Healthcare Improvement Scotland's (HIS) IPC Standards (2022) Standard 1 (Leadership and Governance) addresses the requirement for Infection Control Teams (ICTs) to function effectively as a team, including clear communication lines and regular meetings. The Infection Prevention Workforce Strategic Plan 2022-2024 further addresses team structures within IPC services. The Scottish Government's response (18 June 2015) also highlighted the role of the national HAI Taskforce in coordinating actions with local teams.
NHS Health Boards (Scotland)
(Primary)
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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
Healthcare Improvement Scotland's (HIS) IPC Standards (2022) Standard 4 (Assurance and Monitoring) explicitly requires systematic auditing of adherence to infection prevention and control (IPC) policies. The National Infection Prevention and Control Manual (NIPCM) provides audit tools for health boards to use, and national compliance is monitored through HIS inspections. The Scottish Government's response (18 June 2015) also noted that quality improvement uses audit methods and that a robust HAI scrutiny regime, including Healthcare Environment Inspectorate (HEI) inspections, is in place.
NHS Health Boards (Scotland)
(Primary)
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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
National mandatory Clostridioides difficile infection (CDI) surveillance systems have been operational across NHS Scotland since 2006 for patients aged 65 and over, and since 2009 for all patients aged 15 and over, with real-time capabilities (Public Health Scotland / NSS, 1 September 2025). These systems have contributed to a dramatic decrease in CDI incidence rates, with the rate in 2018 below the Local Delivery Plan target. Public Health Scotland further published dedicated guidance in November 2024 for CDI prevention and control in community-based settings, extending surveillance beyond acute hospitals. The Scottish Government's response (18 June 2015) also highlighted national and local surveillance data collection and eHealth initiatives improving data sharing.
NHS Health Boards (Scotland)
(Primary)
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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
Healthcare Improvement Scotland's (HIS) IPC Standards (2022) Standard 4 (Assurance and Monitoring) addresses the training requirements for users of surveillance systems. The Scottish Infection Prevention and Control Education Pathway (SIPCEP) includes surveillance system training as a component of the broader IPC education pathway, ensuring users are properly trained and aware of how to use and respond to available data. The Scottish Government's response (18 June 2015) also highlighted national education and training initiatives from the HAI Taskforce and the National Infection Prevention and Control Manual.
NHS Health Boards (Scotland)
(Primary)
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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 accepted this recommendation in 2015, noting national surveillance of C. diff infection, inclusion of C. diff targets in Local Delivery Plan Standards, and the use of eHealth systems to improve reporting (Scottish Government's Response, 2015). Public Health Scotland and NSS reported in September 2025 that CDI rates are reported through multiple organisational levels, from ward to Board, and quarterly national surveillance reports are published, ensuring transparency. However, a Scottish Government Oversight Board report from March 2021 identified significant failings in the appropriate escalation of infection data within NHS Greater Glasgow and Clyde, suggesting inconsistent implementation across health boards.
NHS Health Boards (Scotland)
(Primary)
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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 accepted this recommendation in 2015, noting that infection prevention and control is explicitly considered at all clinical governance committee meetings and that the national HAI Taskforce coordinates actions across NHS Scotland (Scottish Government's Response, 2015). Healthcare Improvement Scotland (HIS) IPC Standards (2022) Standard 1 (Leadership and Governance) requires NHS Health Boards to ensure that infection prevention and control groups meet at regular intervals with appropriate upward reporting through the management structure, a requirement monitored through HIS inspections.
NHS Health Boards (Scotland)
(Primary)
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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 accepted this recommendation in 2015, highlighting that registered health professionals must meet professional record-keeping standards and referencing the Scottish Government's Records Management: NHS code of practice (Scotland) (Scottish Government's Response, 2015). Healthcare Improvement Scotland (HIS) IPC Standards (2022) Standard 1 specifically addresses reporting requirements between infection prevention and control committees at different governance levels, ensuring that minutes of meetings and reports are escalated through the hierarchy.
NHS Health Boards (Scotland)
(Primary)
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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 accepted this recommendation in 2015, citing the National Health Service Reform (Scotland) Act 2004, which requires NHS boards to involve the public in service planning and design, and noting the role of the Scottish Health Council and public partnership forums (Scottish Government's Response, 2015). Healthcare Improvement Scotland (HIS) IPC Standards (2022) address governance requirements, and Scottish Government public involvement standards mandate patient and public representation in NHS governance, supporting lay representation at the Board infection prevention and control committee level.
NHS Health Boards (Scotland)
(Primary)
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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 accepted this recommendation in 2015, stating that reducing healthcare-associated infections (HAI) is a priority, supported by a restructured national HAI Taskforce providing leadership (Scottish Government's Response, 2015). Healthcare Improvement Scotland (HIS) IPC Standards (2022) Standard 1 (Leadership and Governance) specifically addresses attendance requirements for infection prevention and control governance meetings, with compliance monitored through HIS inspections.
NHS Health Boards (Scotland)
(Primary)
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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 accepted this recommendation in 2015, noting that the Cleanliness Champions Programme was introduced in September 2003, with over 18,000 NHS Scotland staff having completed it (Scottish Government's Response, 2015). NHS Education for Scotland reported in January 2025 that the programme, having trained over 18,000 healthcare workers, is now integrated into the Scottish Infection Prevention and Control Education Pathway (SIPCEP), which provides a staged pathway of IPC education via the Turas Learn platform.
NHS Health Boards (Scotland)
(Primary)
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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 accepted this recommendation in 2015, highlighting the establishment of the Healthcare Environment Inspectorate (HEI) in April 2009, which conducts at least 30 unannounced inspections annually in healthcare settings, with public volunteers participating to ensure a patient and public view (Scottish Government's Response, 2015). Healthcare Improvement Scotland reported in January 2024 that the HEI continues to conduct unannounced inspections of clinical areas, having completed over 200 inspections since its inception, with public partners participating in some inspection activities.
NHS Health Boards (Scotland)
(Primary)
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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 accepted this recommendation in 2015, noting that the 10 Patient Safety Essentials include leadership walk-rounds, where leaders and frontline staff discuss and reduce barriers to safe care, promoting a safety-aware improvement culture (Scottish Government's Response, 2015). Healthcare Improvement Scotland (HIS) IPC Standards (2022) address management oversight of clinical areas, and weekly senior manager visits with IPC staff are covered by governance standards; however, HIS noted in May 2022 that compliance with this practice varies by health board. No further published evidence has been identified since 2022.
NHS Health Boards (Scotland)
(Primary)
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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 accepted this recommendation in 2015, referencing its policy for all planned new-build hospitals to provide 100% single-room accommodation, with refurbished buildings requiring at least 50% single rooms, and the inclusion of patient placement in Standard Infection Control Precautions (Scottish Government's Response, 2015). Scottish Government policy CEL 48 (2008) mandates these single-room requirements and specifies a 3.6m by 3.7m bed spacing for multi-bed wards, directly supporting the effective isolation of patients suspected of suffering from C. diff infection.
NHS Health Boards (Scotland)
(Primary)
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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's 2015 response outlined a policy to increase single-room accommodation in hospitals, requiring 100% single rooms for new builds and at least 50% for refurbished facilities. Detailed guidance from ARHAI Scotland / NIPCM, updated in July 2022, restricts cohorting to exceptional circumstances when single rooms are unavailable, reinforcing single-room isolation as the default.
NHS Health Boards (Scotland)
(Primary)
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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's 2015 response highlighted Standard Infection Control Precautions (SICPs), which include patient placement for isolation, and a policy for increasing single-room accommodation in hospitals. ARHAI Scotland / NIPCM provides comprehensive and continuously updated guidance, last noted in July 2022, on isolating patients with potentially infectious diarrhoea, detailing both SICPs and transmission-based precautions.
NHS Health Boards (Scotland)
(Primary)
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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's 2015 response referenced the revised NHSScotland National Cleaning Services Specification and its monitoring framework, alongside significant investment in NHS estates between 2014 and 2016. Healthcare Improvement Scotland's IPC Standards (2022) include requirements for the built environment (Standard 8) and equipment cleaning (Standard 7) to support effective infection prevention and control, with HEI inspections assessing compliance.
NHS Health Boards (Scotland)
(Primary)
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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's 2015 response outlined support for HAI education and training, including an education framework for infection prevention and control specialists. NHS Education for Scotland's SIPCEP includes Link Nurse/Link Practitioner training as part of a staged IPC education pathway, with role-specific resources available on the Turas Learn platform, as noted in January 2025.
NHS Health Boards (Scotland)
(Primary)
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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 Certification of Death (Scotland) Act 2011 came into force on 13 May 2015, directly addressing this recommendation. The Death Certification Review Service (DCRS) within Healthcare Improvement Scotland conducts random reviews of death certificates to ensure consultant involvement and accuracy.
NHS Health Boards (Scotland)
(Primary)
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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's 2015 response emphasized person-centred care and providing clear information to relatives. The statutory Duty of Candour was established under the Health (Tobacco Nicotine etc. and Care) (Scotland) Act 2016, with associated 2018 regulations requiring organisations to inform families about safety incidents and provide explanations, including for CDI-related deaths. However, a 2021 report from the QEUH Oversight Board found that the Duty of Candour was not formally activated for infection instances at QEUH, despite deaths linked to the hospital environment, indicating an implementation gap.
NHS Health Boards (Scotland)
(Primary)
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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 requested an assessment of progress from the Crown Office and Procurator Fiscal Service (COPFS) in December 2014. COPFS confirmed in 2015 that it would regularly review its guidance on death reporting and has since revised its Guidance on Investigation of Deaths. However, no publicly available evidence confirms the formal adoption or reporting of a specific two-yearly review cycle as recommended.
COPFS
(Primary)
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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's 2015 response noted the need for improved national monitoring of HAI-related mortality. Public Health Scotland and ARHAI Scotland now provide national mandatory surveillance of C. difficile infection (CDI), which includes monitoring CDI-related deaths, with quarterly reports published and comprehensive surveillance work reflected in the ARHAI Scotland 2024 Annual Report.
Scottish Government
(Primary)
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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's 2015 response indicated that internal investigation independence requirements are addressed through existing governance frameworks and the Code of Corporate Governance for NHS Scotland. However, no specific new mechanism mandating the participation of a non-executive Board Member or a representative from internal audit in all internal investigations has been publicly confirmed since the initial response in 2015.
NHS Health Boards (Scotland)
(Primary)
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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 accepted this recommendation in 2015. The National Infection Prevention and Control Manual (NIPCM) provides detailed guidance on Outbreak Control Team (OCT) reporting standards, as noted in the Scottish Government's response to the Inquiry (18 June 2015). However, no specific enforcement mechanism was created to ensure the sufficiency of detail in OCT3 reports for proper auditing, and no further published evidence has been identified since 2015.
NHS Health Boards (Scotland)
(Primary)
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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 …
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Published evidence summary
The Scottish Government accepted this recommendation in 2015. Antimicrobial Resistance and Healthcare Associated Infection Scotland (ARHAI Scotland) serves as the national body responsible for reviewing UK and international infection prevention and control (IPC) reports as standard practice (ARHAI Scotland, 1 January 2025). ARHAI Scotland's National Policies Guidance and Evidence Working Group continuously reviews published literature and reports to inform national guidance and policy development.
Scottish Government
(Primary)
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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 accepted this recommendation in 2015. Healthcare Improvement Scotland (HIS) published its Infection Prevention and Control (IPC) Standards in May 2022, which include Standard 6 (Evidence-Based Policies) requiring health boards to review published reports and update their policies accordingly. HIS inspections assess health board compliance with learning from external reports (Healthcare Improvement Scotland, 1 May 2022).
NHS Health Boards (Scotland)
(Primary)
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