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24 November 2014, 14:33 | Updated: 24 November 2014, 14:34
An inquiry into a deadly outbreak of Clostridium difficile at a hospital has revealed "serious personal and systemic failures''.
The probe was set up in 2009 to investigate the treatment of 63 patients at the Vale of Leven Hospital in West Dunbartonshire between December 1 2007 and June 1 2008.
Inquiry chairman Lord MacLean published the report today, and it found C.diff was a factor in the death of 34 out of 143 patients who had tested positive for the infection at the hospital during the period January 2007 to December 31 2008.
Unveiling the findings at the Royal College of Physicians and Surgeons in Glasgow, Lord MacLean said patients had been badly let down by NHS Greater Glasgow and Clyde.
He 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.
"There were failures by individuals but the overall responsibility has to rest with the health board.
"The Scottish ministers bear ultimate responsibility for NHS Scotland and, even at the level of the Scottish Government, systems were simply not adequate to tackle effectively a healthcare-associated infection like CDI (C.diff).
"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 is probably an underestimate as medical records were not available for all of the patients during the period in question.
There are 75 recommendations in the report covering areas including infection prevention and control, nursing and medical care and antibiotic prescribing.
Labour MSP for Dumbarton Jackie Baillie said: "Today is a day of mixed emotions for the families of those who lost their lives between 2007 and 2008. They were vindicated in their call for a public inquiry as the report identified significant failings at every level of the health service and government.
"The C.Diff outbreak at the Vale of Leven Hospital was the worst in the UK due to the high mortality rate.
"The families deserve nothing less than a full apology from the hospital management, NHS Greater Glasgow and Clyde and the Scottish Government for the mistakes which compromised patient care.
"What happened at the Vale of Leven should never be repeated anywhere in Scotland so it is vital we learn lessons and implement MacLean's recommendations in full.''