article: The probe, led by Lord MacLean, looked into care at Dunbartonshire's Vale of Leven Hospital between 2007 and 2008. Of the 143 patients with C. diff, it was a contributory factor in 34 deaths. Lord MacLean said NHS Greater Glasgow and Clyde (GGC) had "badly let down" patients. The health board apologised unreservedly for a "terrible failure". The judge said: "The inquiry has discovered serious personal and systemic failures. "Patients at the Vale of Leven Hospital were badly let down by people at different levels of NHS Greater Glasgow and Clyde who were supposed to care for them." He added: "There were failures by individuals but the overall responsibility has to rest with the health board." Lord MacLean said "systems were simply not adequate to tackle effectively a healthcare associated infection" like C. diff. He added: "The major lesson to be learned is that what happened at Vale of Leven Hospital to cause such personal suffering should never be allowed to happen again." Lord MacLean also expressed his view that the figure of 34 deaths was probably an underestimate as medical records were not available for all of the patients during the period in question. He cited poor facilities, such as a lack of wash hand basins and a lack of commodes, as well as issues with the fabric of the building as evidence of poor management. The judge said that prolonged uncertainty over the future of the Vale of Leven hospital contributed to poor morale and recruitment. Poor leadership among NHS GGC managers, the judge said, contributed to substandard nursing care and deficiencies in medical staffing. He said inexperienced junior doctors had too much responsibility and consultants were stretched. Lord MacLean also said antibiotics were prescribed in cases where it was inappropriate. His report identified a number of failings: There are 75 recommendations in his report, including recommendations on infection prevention and control, nursing and medical care, antibiotic prescribing, communication with patients and relatives, and death certification. Lord MacLean added: "An effective inspection regime, I am convinced, would have been able to identify the dysfunctional nature of infection prevention and control at the hospital. "There must be an effective line of reporting, accountability and assurance. "This was lacking for the Vale of Leven Hospital. In addition, repeated warnings over a number of years about the importance of prudent antibiotic prescribing had no impact." C. diff Inquiry C. diff is a bacteria which lives harmlessly in the gut of 10% to 15% of adults. It causes diarrhoea when the delicate balance of gut flora is disturbed, often following a course of antibiotics. It is easily spread via airborne spores. The inquiry into the C. diff outbreak at vale of Leven was delayed five times. The eventual cost of the inquiry is estimated to be just under Â£10m. Lord MacLean acknowledged that improvements had been made since the C. diff outbreak. He said: "NHS Greater Glasgow and Clyde did introduce more effective reporting systems for CDI (C. diff) after June 2008 but the message should be reinforced that systems must ensure that important
summary: Scotland's largest health board has been heavily criticised by an inquiry into the country's worst Clostridium difficile (C. diff) outbreak.