A SCANDAL-hit health board downgraded an infection linked to the death of a 10-year-old girl two weeks before she died.
Milly Main contracted Stenotrophomonas maltophilia while in Glasgow’s Royal Hospital for Children (RHC), in July 2017, and passed away on August 31 that year.
However experts from NHS Greater Glasgow and Clyde (NHSGGC) investigating Milly’s infection, and another patient with the same bug, downgraded the incident from the highest threat level - red- to the lowest - green when they determined the two cases were not linked.
An investigation by the Herald on Sunday can also reveal that NHSGGC’s infection control doctor asked for the RHC’s water supply to be tested for the bacteria just three days after Milly’s infection was first recorded.
More than 100 samples were eventually tested, but all returned negative results.
Previously the health board said no such testing was ever done as “we did not consider this to be the source at the time and we did not test for the particular infection in the water supply.”
Milly’s mother has now issued another desperate plea to find out the truth about her daughter’s infection, saying the ordeal has brought “back all the pain we suffered”.
Kimberley Darroch maintains she was not informed about her daughter’s infection until she saw it listed on Milly’s death certificate, but said she is convinced the bacteria came from the water at the hospital.
Ms Darroch said she is desperate to know what happened to prevent any other families going through the same pain she has experienced.
She said: “The health board kept us all in the dark.
“Senior managers knew why Milly had died, but nobody explained it to us, and now it appears they didn’t tell the government the full story either.
“All we want is to be told the truth, so that no other parent has to go through what we’re going through – finding out information years later and bringing back all the pain we suffered.”
NHSGGC confirmed that their lead infection control doctor asked for the water supply at the hospital to be tested for Stenotrophomonas on August 1 but said there were no such tests available as they had never been done before.
It took six weeks for scientists to develop the tests, by which time Milly had passed away.
Between September 4 and 14, 117 water samples were examined for the bacteria but all came back negative, however a spokeswoman said due to the time between Milly becoming infected and the tests being carried out, it was not “possible to be completely certain” that the bacteria did not come from the water.
A further 10 cases of the bacterial infection, which have been linked to the water system, were recorded at the children’s hospital between 2016 and 2018.
Labour MSP Anas Sarwar has criticised the government and health board claiming they have failed to tell the truth about Milly’s death, and reiterated his accusation the case was a “cover up”.
He said: “This drip-drip of information regarding Milly’s death is simply unacceptable.
“Kimberly and her family deserve full transparency about Milly’s tragic death.
“We need to know who at the Scottish Government was aware of the circumstances of her infection and what follow-up action was taken, but – more importantly – we need to know why the health board didn’t report Milly’s subsequent death [to the government].
“This is a cover-up by the health board, which is why those in charge should be removed from their jobs while a full independent investigation takes place.”
Government officials and health watchdogs Health Protection Scotland (HPS) were told about the Stenotrophomonas cases on July 27, but due to the downgrading of the infections, there was no requirement for the government or then-health minister to be kept up to date with any subsequent developments.
HPS was told about Milly’s death on September 4, 2017, according to the health board, however this information was not relayed to the government.
Health secretary Jeane Freeman said she had no knowledge of Milly’s case until Ms Darroch wrote to her about it in 2018.
When asked if she had spoken to her predecessor Shona Robison when she took over the role in the summer of 2018, Ms Freeman told the Herald on Sunday that “the handover was more led by senior officials” as “its something they are dealing with daily.”
A Scottish Government spokeswoman said: “The Scottish Government was informed of 2 positive cases of Stenotrophomonas maltophilia bloodstream infections within Ward 2A (Royal Hospital for Children) on 27 July 2017, but that notification contained no patient identifying information. We now subsequently understand that one of the two cases was Milly Main.
“The incident was initially assessed as ‘Red’ on 27 July 2017, however was de-escalated to ‘Green’ on 15 August 2017 as further analysis found the organisms were different types. In accordance with normal practice in relation to incidents assessed as ‘Green’, the Scottish Government did not receive any further updates.
“Therefore the subsequent tragic death of Milly Main on 31 August 2017 was not reported to the Scottish Government and Ministers were not briefed at that time.
“There is currently no requirement for the board to report HCAI [healthcare associated infection] deaths to Scottish Government.”
Jane Grant, Chief Executive of NHSGGC said: “I am truly sorry for the distress and pain being caused to Milly’s family at this time.
“I am fully committed to doing everything possible to answer her questions and I hope to meet Ms Darroch to discuss her daughter’s care.
“We have written to Ms Darroch to offer a further meeting and await her response.”
A spokeswoman for HPS, said:“We are unable to comment on individual cases. Additionally all information received via reporting methods is non patient identifiable.”
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