A health watchdog will carry out a national review of the water systems at all healthcare facilities in Scotland built since 2013 to avoid a repeat of an infection outbreak at a children’s hospital.
Health Protection Scotland (HPS) launched an investigation after patients in wards for those with compromised immune systems at the Royal Hospital for Children (RHC) in Glasgow were found to have infections.
An HPS investigation report states the first child was infected in 2016, with a total of 25 cases found by September 2018, when the patients were moved out of the wards 2A/B and into the neighbouring Queen Elizabeth University Hospital (QEUH).
No patients died as a result of the outbreak, but a number of children required “additional intervention” and there were delays to chemotherapy treatments.
Tests found “widespread contamination of the water system that serves both QEUH and RHC”.
This included contamination on taps and drains in the affected wards, and the system there was sanitised, with water filters put in place, and drains were decontaminated prior to the patients being moved.
Now, as part of a series of recommendations, HPS plans to “undertake an urgent national water review of all healthcare premises built since 2013 to provide assurance that a similar incident has not and is not likely to occur elsewhere”.
The report said the most likely cause is thought to be a possible combination of existing contamination at the installation and/or commissioning of the water system and contamination at taps spreading backwards.
Water samples showed indicators of contamination prior to handover and the contractor sanitised the system but there were some indications there may still have been areas with higher than acceptable levels of the contamination indicator.
Part of a water treatment system installed involves continual dosing with chlorine dioxide which the report said may take up to two years to be effective throughout the system.
A spokeswoman for the health board said: “There have been no cases of infection associated with water since September 2018.
“Our engineering teams have installed a water treatment system within the Royal Hospital for Children and are working on the new system for the adult hospital. This will be completed in March.
“In the meantime, filters remain in place and we continue to monitor the quality of water with very encouraging results.
“Over the past few months, whilst our investigations continued, our overriding priority has always been the safety of our patients.
“We are sorry that a number of young patients in our care suffered an infection and also apologise for the inconvenience and worry that the families in wards 2A and B in particular will have experienced.”
She added that four reviews into the hospital have been announced since the report was written in December 2018.
Health Secretary Jeane Freeman said: “The report makes a number of important recommendations for NHS Greater Glasgow and Clyde, as well as all NHS boards, Health Protection Scotland and Health Facilities Scotland.
“It is vital that these recommendations are addressed.
“NHS Greater Glasgow and Clyde continue to take the necessary actions and I will continue to seek regular updates on these actions to ensure full accountability of the board.
“I will also ensure that work is taken forward on the wider recommendations to ensure key lessons can be learned Scotland-wide to prevent similar issues arising in the future and ensure our healthcare facilities support the delivery of world-class health care.”