Health chiefs 'ignored the law' by failing to report Milly Main's death to prosecutors

Milly died on August 31, 2017, having contracted Stenotrophomonas in her line used to administer medicines.

A whistleblower said the bacteria had been in water at the RHC, and a report from 2018 said the same bacteria was associated with more than a dozen water-related infections in children.

Her family were not told at the time that the bacterial infection was linked to contaminated water at the hospital, or that it was a cause of her death.

They only discovered later by looking at Milly’s death certificate, following the series of infection scandals which have emerged about the RHC and Queen Elizabeth University Hospital (QEUH).

Milly’s mother Kimberley Darroch said she was “very surprised” that her daughter’s death had not been reported to prosecutors after being informed by The Herald on Sunday.

She said: “Nobody explained to us the possible cause of Milly’s death at the time.

“It has been incredibly hard reliving the pain of Milly’s death in recent weeks, but we are very grateful to the whistleblowers and others who have come forward and would like to thank everyone for their support.

“I believe Milly would still be alive today if hospital managers had listened to all the warnings of infection risk when the building first opened.

“As a family we will consider all options so that we can get answers about Milly’s death, and so that no family has to go through this ordeal again. We can’t wait for a public inquiry.

“I have no faith in this health board and its leadership. We will only have a truly independent inquiry if they are moved aside.”

According to the prosecutor’s protocols, any death should be reported by medics in charge of the patient if it raises issues of public safety.

A report by clinicians in 2017, detailed by a newspaper two weeks ago, revealed that there were 26 cases of infections potentially linked to contaminated water on the same ward as where Milly was being treated.

Crucially, guidelines clearly state that “where, at any time, a death certificate has been issued and a complaint is later received ... which suggests that an act or omission by medical staff caused or contributed to the death” that death should be reported to the procurator fiscal.

A death can also be reported when “the circumstances might indicate fault or neglect on the part of medical staff or where medical staff have concerns regarding the circumstances of death”.

Other health boards’ own policy documents state that any death where the person had a hospital-acquired infection must be reported.

Sources working at the QEUH said they were aware that Milly’s death had not been reported, but say that “it categorically should have been”.

One senior figure said: “Another boy who passed away ... his death was reported, and he was on the same ward. I do not understand why Milly’s death wasn’t. It continues to look as if the board covered this up.

“The family wouldn’t have complained at the time as they didn’t even know that their child’s death was linked to the water. They weren’t told.”

Anas Sarwar, the Glasgow Labour MSP, has been working with Ms Darroch on her case.

He said: “If the procurator fiscal wasn’t informed at the time of Milly’s death, that raises serious fresh questions.

“Health board chiefs kept Milly’s parents in the dark, and that is totally unforgivable.

“It took a brave whistleblower to come forward to reveal what happened, and if health board managers had their way then this would still be covered up.

“I will stand by Milly’s family with whatever decision they take – they deserve answers and they deserve justice, as does every family affected.”

His colleague Monica Lennon, Labour’s health spokeswoman, said that NHSGGC had been “too secretive” about infections at the site.

She said: “Scottish Labour contacted the Crown Office and Procurator Fiscal Service earlier this year with questions about hospital-acquired deaths, because of our concerns over transparency at NHS Greater Glasgow and Clyde.

“The health board has been too secretive about infections and unexpected deaths at the hospital but the law is very clear on what should be reported.

“Unfortunately, families and patients no longer trust what the health board is saying, and grieving families have been treated appallingly.

“It beggars belief that the leadership team hasn’t been moved aside. The Health Secretary has been too soft for too long and the public fears an infections cover-up at the QEUH.

“We need a categoric assurance

from Jeane Freeman that NHSGCC and all health boards in Scotland are complying with the law.

“There can be no exceptions. All health boards should be following the correct reporting procedures in relation to hospital deaths.”

NHS Greater Glasgow and Clyde said that they followed protocols and a spokeswoman added: “The procurator fiscal sets out clear advice to medical practitioners on the circumstances when a death should be reported and these were followed in this case.

“In doing so, we took into account that the family had no concerns or complaints about the treatment or care provided to Milly at the time.”

The spokeswoman added: “The death of any child is a tragedy and we continue to offer our sympathies to Milly’s family for their loss.

“We have written to Milly’s mother this week to answer a number of her questions.

“We have also updated her on the significant amount of work under way to review Milly’s case.”

Jane Grant, chief executive of NHSGGC, has been facing calls to resign over the scandals at the £842 million superhospital campus and subsequent lack of communication with the public and families involved.

Last week, she said that it “had not been easy given the challenges we inherited from the previous leadership team” – a claim which her predecessor Bob Calderwood dismissed, saying the majority of top staff at the health board had remained unchanged.

Grant said: “I am truly sorry for the distress and pain being caused to Milly’s family by the uncertainty that has surrounded questions about the water supply and whether it was the source of Milly’s infection.

“Milly’s family deserves answers. We owe it them to thoroughly and fully re-examine the investigations that took place.

“We want to do anything we can to answer her questions. We have written to her this week and remain keen to meet Ms Darroch to discuss these results in more detail with her.”