Hansard

I start by sending my condolences to anyone affected by the tragic events at the Queen Elizabeth hospital in Glasgow. Nothing that we say or do in the chamber today will bring their loved ones back or offer any comfort.

Secondly, there are the hard-working staff who cared for those people’s loved ones and who still care for our loved ones on a daily basis under immense pressure from the current circumstances.

The fateful mistakes that led to Milly Main’s death, as set out in great detail by Mr Sarwar, continue to shock us all, as is apparent from the debate, but Milly’s death, and the needless infection of countless children at the hospital, was not just a tragedy, an accident or a mistake; it was a failure of governance at so many steps along the way—whether from the procurement and its oversight, the build itself, the building’s release to the health board, the working culture or the way in which concerns were raised and subsequently investigated. It is not the fault of the front-line staff, who were asked to go above and beyond. They had themselves flagged concerns to senior management at the hospital.

It is claimed that the health board knew about contaminated water as far back as 2015, when it took the keys of the hospital from the contractors. The question is what was done about it and whether that went far enough to mitigate the potential risk of the tragedy that actually ensued. We know that infection control doctors raised multiple concerns on multiple occasions, and even reported them to Health Protection Scotland in 2017. Despite all of that, the then health secretary, Jeane Freeman, told Parliament that she only found out on 11 March 2018, more than six months after the first potential water contamination death at the hospital. That begs the question: why did something so profoundly serious not land on her desk prior to that? I do not know what is a worse or more depressing scenario: that no one in Government knew about it before then, or that they did know but kept it quiet. Only one of those can be true.

Milly died from an infection that she acquired at the hospital that was meant to take care of her and make her better. In fact, she was getting better, until the infection. However, she and 83 other children were infected by the same bacteria and a third of them suffered severe health impacts as a result. Who has really taken full responsibility for all of that? Who was sacked? Who was sued? Who was prosecuted? The answer is no one.

Ms Freeman—for whom I had and still have a lot of respect—is no longer here to account for the Government; all the while, the contractors are mired in legal disputes with the health board and the health board recently gave its own senior management team an “Excellence in Leadership” award. I cannot begin to imagine how galling that is for the families affected by this tragedy.

Warnings were ignored and action was not taken and I am afraid that that ultimately led to the death of a child. If that had happened in the private sector, we would not be talking about public inquiries but criminal prosecutions. The reality is that we talk so often about these eponymous laws, which bear the names of the victims of tragedies, and we do so usually because the legislation is either too weak or simply non-existent.

We have Michelle’s law, Suzanne’s law, Frank’s law, Anne’s law and now Milly’s law. Behind every law is a name and behind every name is a victim. Every one of those laws should shame the Government for its actions or its inaction. It is failed governance, failed transparency and poor or non-existent communication that lie at the heart of so many of the problems here.

Four years on, we are still talking about solutions. We should not need a new law to stop tragedies such as this one. I have two quick points to make. First, far too often whistleblowers are not taken seriously and they are branded as troublemakers. There needs to be a cultural shift, not just in the NHS but in so many of our public bodies.

My last point is on the erosion of local services. If we are going to move services from places such as Inverclyde Royal hospital in Greenock and centralise them at a super-hospital, patients must find that those services are improved. Patients must have complete faith in the place that they are being moved to. The pain of the longer commute and fewer visitors needs to be compensated for by better outcomes.

It all comes back down to the families. The father of one child who became infected at the Queen Elizabeth said:

“When you see the fear in doctors’ eyes, the fear of ... intelligent people ... that’s scary ... we ... steeled ourselves for dealing with cancer ... what we didn’t expect was to be put in a position where a building almost killed our son.”

That family was one of the luckier ones. Milly’s was not. These families do not want more reviews; they want more honesty and more action, and they deserve it.