Public Inquiry Recommendations

R1 Accepted

Vale of Leven Inquiry (2014)

HEI ward closure powers

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 …

- The Scottish Government published its response to the Vale of Leven Hospital Inquiry Report on 18 June 2015, accepting all 75 recommendations and establishing …

R2 Accepted

Vale of Leven Inquiry (2014)

HAI implementation strategy

Scottish Government should ensure that policies and guidance on healthcare associated infection are accompanied by an implementation strategy and that implementation is monitored.

- The Scottish Government published its response to the Vale of Leven Hospital Inquiry Report on 18 June 2015, accepting all 75 recommendations and establishing …

R3 Accepted

Vale of Leven Inquiry (2014)

IPC policy review

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.

- The Scottish Government published its response to the Vale of Leven Hospital Inquiry Report on 18 June 2015, accepting all 75 recommendations and establishing …

R4 Accepted

Vale of Leven Inquiry (2014)

Local HAI Task Forces

Scottish Government should develop local healthcare Associated infection (HAI) Task Forces within each Health Board area.

- The Scottish Government published its response to the Vale of Leven Hospital Inquiry Report on 18 June 2015, accepting all 75 recommendations and establishing …

R5 Accepted

Vale of Leven Inquiry (2014)

Hospital future uncertainty resolution

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.

- The Scottish Government published its response to the Vale of Leven Hospital Inquiry Report on 18 June 2015, accepting all 75 recommendations and establishing …

R6 Accepted

Vale of Leven Inquiry (2014)

Service change continuity plans

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.

- The Scottish Government published its response to the Vale of Leven Hospital Inquiry Report on 18 June 2015, accepting all 75 recommendations and establishing …

R7 Accepted

Vale of Leven Inquiry (2014)

Reorganisation due diligence

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.

- The Scottish Government published its response to the Vale of Leven Hospital Inquiry Report on 18 June 2015, accepting all 75 recommendations and establishing …

R8 Accepted

Vale of Leven Inquiry (2014)

Reorganisation management structure

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.

- The Scottish Government published its response to the Vale of Leven Hospital Inquiry Report on 18 June 2015, accepting all 75 recommendations and establishing …

R9 Accepted

Vale of Leven Inquiry (2014)

IPC clinical governance meetings

Health Boards should ensure that infection prevention and control is explicitly considered at all clinical governance committee meetings from local level to Board level.

- The Scottish Government published its response to the Vale of Leven Hospital Inquiry Report on 18 June 2015, accepting all 75 recommendations and establishing …

R10 Accepted

Vale of Leven Inquiry (2014)

CDI patient information

Health Boards should ensure that patients diagnosed with CDI are given information by medical and nursing staff about their condition and prognosis.

- The Scottish Government published its response to the Vale of Leven Hospital Inquiry Report on 18 June 2015, accepting all 75 recommendations and establishing …

R11 Accepted

Vale of Leven Inquiry (2014)

CDI severity awareness

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.

- The Scottish Government published its response to the Vale of Leven Hospital Inquiry Report on 18 June 2015, accepting all 75 recommendations and establishing …

R12 Accepted

Vale of Leven Inquiry (2014)

CDI infection control advice

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.

- The Scottish Government published its response to the Vale of Leven Hospital Inquiry Report on 18 June 2015, accepting all 75 recommendations and establishing …

R13 Accepted

Vale of Leven Inquiry (2014)

Clear nursing responsibility line

Health Boards should ensure that there is a clear and effective line of professional responsibility between the ward and the Board.

- The Scottish Government published its response to the Vale of Leven Hospital Inquiry Report on 18 June 2015, accepting all 75 recommendations and establishing …

R14 Accepted

Vale of Leven Inquiry (2014)

Patient records compliance audit

Health Boards should ensure that the nurse in charge of each ward audits compliance with the duty to keep clear and contemporaneous patient records.

- The Scottish Government published its response to the Vale of Leven Hospital Inquiry Report on 18 June 2015, accepting all 75 recommendations and establishing …

R15 Accepted

Vale of Leven Inquiry (2014)

CDI patient observations records

Health Boards should ensure that nursing staff caring for a patient with CDI keep accurate records of patient observations including temperature, pulse, respiration.

- The Scottish Government published its response to the Vale of Leven Hospital Inquiry Report on 18 June 2015, accepting all 75 recommendations and establishing …

R16 Accepted

Vale of Leven Inquiry (2014)

CDI outbreak reporting

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.

- The Scottish Government published its response to the Vale of Leven Hospital Inquiry Report on 18 June 2015, accepting all 75 recommendations and establishing …

R17 Accepted

Vale of Leven Inquiry (2014)

Ward admission responsibility

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 …

- The Scottish Government published its response to the Vale of Leven Hospital Inquiry Report on 18 June 2015, accepting all 75 recommendations and establishing …

R18 Accepted

Vale of Leven Inquiry (2014)

Care planning system

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.

- The Scottish Government published its response to the Vale of Leven Hospital Inquiry Report on 18 June 2015, accepting all 75 recommendations and establishing …

R19 Accepted

Vale of Leven Inquiry (2014)

ICN instructions recorded

Health Boards should ensure that where Infection Control Nurses provide instructions on the management of patients those instructions are recorded in patient notes.

- The Scottish Government published its response to the Vale of Leven Hospital Inquiry Report on 18 June 2015, accepting all 75 recommendations and establishing …

R20 Accepted

Vale of Leven Inquiry (2014)

Stool records for CDI patients

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.

- The Scottish Government published its response to the Vale of Leven Hospital Inquiry Report on 18 June 2015, accepting all 75 recommendations and establishing …

R21 Accepted

Vale of Leven Inquiry (2014)

Nursing staff for relatives

Health Boards should ensure that a member of nursing staff is available to deal with questions from relatives during visiting periods.

- The Scottish Government published its response to the Vale of Leven Hospital Inquiry Report on 18 June 2015, accepting all 75 recommendations and establishing …

R22 Accepted

Vale of Leven Inquiry (2014)

Relative discussions recorded

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.

- The Scottish Government published its response to the Vale of Leven Hospital Inquiry Report on 18 June 2015, accepting all 75 recommendations and establishing …

R23 Accepted

Vale of Leven Inquiry (2014)

TVN training and qualification

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.

- The Scottish Government published its response to the Vale of Leven Hospital Inquiry Report on 18 June 2015, accepting all 75 recommendations and establishing …

R24 Accepted

Vale of Leven Inquiry (2014)

TVN instructions recorded

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 …

- The Scottish Government published its response to the Vale of Leven Hospital Inquiry Report on 18 June 2015, accepting all 75 recommendations and establishing …

R25 Accepted

Vale of Leven Inquiry (2014)

Pressure damage risk assessment

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.

- The Scottish Government published its response to the Vale of Leven Hospital Inquiry Report on 18 June 2015, accepting all 75 recommendations and establishing …

R26 Accepted

Vale of Leven Inquiry (2014)

Wound documentation

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 …

- The Scottish Government published its response to the Vale of Leven Hospital Inquiry Report on 18 June 2015, accepting all 75 recommendations and establishing …

R27 Accepted

Vale of Leven Inquiry (2014)

Positional change records

Health Boards should ensure that where a patient requires positional changes nursing staff clearly record this on a turning chart or equivalent.

- The Scottish Government published its response to the Vale of Leven Hospital Inquiry Report on 18 June 2015, accepting all 75 recommendations and establishing …

R28 Accepted

Vale of Leven Inquiry (2014)

Nutritional screening

Health Boards should ensure that all patients have their nutritional status screened on admission to a ward using a recognised nutritional screening tool.

- The Scottish Government published its response to the Vale of Leven Hospital Inquiry Report on 18 June 2015, accepting all 75 recommendations and establishing …

R29 Accepted

Vale of Leven Inquiry (2014)

Patient weighing equipment

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.

- The Scottish Government published its response to the Vale of Leven Hospital Inquiry Report on 18 June 2015, accepting all 75 recommendations and establishing …

R30 Accepted

Vale of Leven Inquiry (2014)

Fluid balance monitoring

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.

- The Scottish Government published its response to the Vale of Leven Hospital Inquiry Report on 18 June 2015, accepting all 75 recommendations and establishing …

R31 Accepted

Vale of Leven Inquiry (2014)

Staffing and skills mix review

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.

- The Scottish Government published its response to the Vale of Leven Hospital Inquiry Report on 18 June 2015, accepting all 75 recommendations and establishing …

R32 Accepted

Vale of Leven Inquiry (2014)

Staffing concerns escalation

Health Boards should ensure that there is straightforward and timely escalation process for nurses to report concerns about staffing numbers/skill mix.

- The Scottish Government published its response to the Vale of Leven Hospital Inquiry Report on 18 June 2015, accepting all 75 recommendations and establishing …

R33 Accepted

Vale of Leven Inquiry (2014)

Nursing complaint investigation

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.

- The Scottish Government published its response to the Vale of Leven Hospital Inquiry Report on 18 June 2015, accepting all 75 recommendations and establishing …

R34 Accepted

Vale of Leven Inquiry (2014)

Antimicrobial guidance implementation

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.

- The Scottish Government published its response to the Vale of Leven Hospital Inquiry Report on 18 June 2015, accepting all 75 recommendations and establishing …

R35 Accepted

Vale of Leven Inquiry (2014)

Antibiotic prescribing monitoring

Scottish Government should monitor the implementation of policies and/or guidance on antibiotic prescribing issued in connection with healthcare associated infection.

- The Scottish Government published its response to the Vale of Leven Hospital Inquiry Report on 18 June 2015, accepting all 75 recommendations and establishing …

R36 Accepted

Vale of Leven Inquiry (2014)

Medical staffing levels

Health Boards should ensure that the level of medical staffing planned and provided is sufficient to provide safe high-quality care.

- The Scottish Government published its response to the Vale of Leven Hospital Inquiry Report on 18 June 2015, accepting all 75 recommendations and establishing …

R37 Accepted

Vale of Leven Inquiry (2014)

CDI senior assessment and treatment

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.

- The Scottish Government published its response to the Vale of Leven Hospital Inquiry Report on 18 June 2015, accepting all 75 recommendations and establishing …

R38 Accepted

Vale of Leven Inquiry (2014)

Medical record keeping

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.

- The Scottish Government published its response to the Vale of Leven Hospital Inquiry Report on 18 June 2015, accepting all 75 recommendations and establishing …

R39 Accepted

Vale of Leven Inquiry (2014)

DNAR decision awareness

Health Boards should ensure that medical and nursing staff are aware that a DNAR1 decision is an important aspect of care.

- The Scottish Government published its response to the Vale of Leven Hospital Inquiry Report on 18 June 2015, accepting all 75 recommendations and establishing …

R40 Accepted

Vale of Leven Inquiry (2014)

Prudent antibiotic prescribing

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.

- The Scottish Government published its response to the Vale of Leven Hospital Inquiry Report on 18 June 2015, accepting all 75 recommendations and establishing …

R41 Accepted

Vale of Leven Inquiry (2014)

Laboratory specimen processing

Health Boards should ensure that there is no unnecessary delay in processing laboratory specimens, in reporting positive results and in commencing specific antibiotic treatment.

- The Scottish Government published its response to the Vale of Leven Hospital Inquiry Report on 18 June 2015, accepting all 75 recommendations and establishing …

R42 Accepted

Vale of Leven Inquiry (2014)

Mandatory IPC training

Health Boards should ensure that all those working in a healthcare setting have mandatory infection prevention control training that includes CDI on appointment.

- The Scottish Government published its response to the Vale of Leven Hospital Inquiry Report on 18 June 2015, accepting all 75 recommendations and establishing …

R43 Accepted

Vale of Leven Inquiry (2014)

IPC staff regular training

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.

- The Scottish Government published its response to the Vale of Leven Hospital Inquiry Report on 18 June 2015, accepting all 75 recommendations and establishing …

R44 Accepted

Vale of Leven Inquiry (2014)

IPC staff appraisals

Health Boards should ensure that performance appraisals of infection prevention and control staff take place at least annually.

- The Scottish Government published its response to the Vale of Leven Hospital Inquiry Report on 18 June 2015, accepting all 75 recommendations and establishing …

R45 Accepted

Vale of Leven Inquiry (2014)

Manager IPC job description

Health Boards should ensure that where a manager has responsibility for oversight of infection prevention control, this is specified in the job description.

- The Scottish Government published its response to the Vale of Leven Hospital Inquiry Report on 18 June 2015, accepting all 75 recommendations and establishing …

R46 Accepted

Vale of Leven Inquiry (2014)

ICM direct responsibility

Health Boards should ensure that the Infection Control Manager has direct responsibility for the infection prevention control service and its staff.

- The Scottish Government published its response to the Vale of Leven Hospital Inquiry Report on 18 June 2015, accepting all 75 recommendations and establishing …

R47 Accepted

Vale of Leven Inquiry (2014)

ICM reports to CEO

Health Boards should ensure that the Infection Control Manager reports direct to the Chief Executive or, at least, to an executive board member.

- The Scottish Government published its response to the Vale of Leven Hospital Inquiry Report on 18 June 2015, accepting all 75 recommendations and establishing …

R48 Accepted

Vale of Leven Inquiry (2014)

ICM Board HAI reporting

Health Boards should ensure that the ICM is responsible for reporting to the Board on the state of HAI in the organisation.

- The Scottish Government published its response to the Vale of Leven Hospital Inquiry Report on 18 June 2015, accepting all 75 recommendations and establishing …

R49 Accepted

Vale of Leven Inquiry (2014)

National ICM role guidance

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.

- The Scottish Government published its response to the Vale of Leven Hospital Inquiry Report on 18 June 2015, accepting all 75 recommendations and establishing …

R50 Accepted

Vale of Leven Inquiry (2014)

24/7 IPC cover

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.

- The Scottish Government published its response to the Vale of Leven Hospital Inquiry Report on 18 June 2015, accepting all 75 recommendations and establishing …