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25 November 2014, 06:17 | Updated: 25 November 2014, 06:27
Medical bodies have said that lessons must be learned from an inquiry into a deadly Clostridium difficile outbreak at a hospital.
The probe into the treatment of patients at the Vale of Leven Hospital in West Dunbartonshire revealed C.diff was a factor in the death of 34 out of 143 patients who had tested positive for the infection during the period January 1 2007 to December 31 2008.
Scotland's new Health Secretary Shona Robison and bosses of NHS Greater Glasgow and Clyde have both apologised after the inquiry found ''serious personal and systemic failures''.
Healthcare professionals said there is no room for complacency, despite changes having been made since 2007, and called for the recommendations in the report to be implemented quickly.
Theresa Fyffe, director of the Royal College of Nursing Scotland, said: "The outbreak of C.difficile had devastating consequences for patients and their families, so it's vital that lessons are learned to prevent any such incident happening in future.
"Clearly, there were issues in many areas and this report makes difficult reading for nurses everywhere. It shows what can happen when there are failings at all levels from the ward to the board room to national government.
"It is right for Lord MacLean to say that senior charge nurses are accountable for what happens on their wards but as he also points out, governance and management failures at Vale of Leven meant nurses were seeking to do their best in an environment where patient care was compromised and infection control was inadequate.
"All health boards now need to assure themselves that they have the right systems in place to allow effective monitoring of fundamental nursing care so that patients are not put in harm's way.''
The British Medical Association (BMA) Scotland said doctors are determined to work with all those involved in planning and delivering NHS services to learn from the mistakes at the Vale of Leven.
Dr Charles Saunders, chairman of the BMA's Scottish public health committee, said: "This report is uncomfortable reading for all of us involved in the provision of healthcare. It highlights a series of events that led to a significant systematic failure in the quality of patient care and it is clear that lessons must be learned.
"Whilst we recognise, since the beginning of this inquiry, a number of steps have been taken to improve patient safety and the standards of care, it is important that the NHS and the Scottish Government are not complacent; some of the circumstances that led to the challenges which were experienced at the Vale of Leven Hospital still exist, and not just in small district general hospitals.''
Professor Derek Bell, president of the Royal College of Physicians of Edinburgh, said: "The report includes a number of valuable findings and recommendations which the profession and all working within health must digest and respond to. Managers and clinicians must work together to ensure all the recommendations are quickly implemented. We cannot allow a recurrence of the events reported.
"While good progress has been made in reducing C.difficile in Scottish hospitals since 2007, there is no room for complacency. We must remain ever vigilant to the risks posed by all healthcare acquired infections and continue to improve our infection control procedures. As the range of drug-resistant infections increases, we must also ensure that antibiotics are used appropriately and welcome the recent promotion of antibiotic guardians within the NHS to encourage this.''
He also said there must be enough consultants with sufficient time to provide clinical leadership, supervision of trainees and high quality care for all patients.
Ms Robison, who was appointed Health Secretary on Friday, said the Scottish Government accepted all of the report's 75 recommendations.
Unison welcomed the publication of the report.
Regional organiser Matt McLaughlin said: "Unison is pleased this report in now finally published and we want to work with our members to ensure patients are put first right across the NHS in Scotland.
"Effective systems of cleaning, safe staffing levels and a focus on patients and patient-facing workers is key to ensuring there is not a repeat of this tragedy.''