A children’s hospital was delayed after a mistake in a spreadsheet several years previously was not amended, a report has found.
The Royal Hospital for Children and Young People in Edinburgh was due to open in July 2019 but Scotland’s Health Secretary Jeane Freeman halted the move from the existing hospital site after final compliance checks revealed the ventilation system within the critical care department of the new building did not meet the necessary standards.
A review commissioned by NHS Lothian found that an “environmental matrix” spreadsheet in 2012 wrongly stated the air change rate in critical care rooms should be four changes per hour, rather than 10.
It said this appears to be “human error in copying across the four-bedded room generic ventilation criteria into the critical care room detail”.
The error was not corrected over the years and the report said that the settlement signed by NHS Lothian in February 2019 “cemented the error contractually”.
The report, by auditors Grant Thornton, stated: “Based on our review of the comments across each version of the matrix, no explicit concern was noted on the environmental matrix recording that what was set out in the matrix for critical care was incorrect.
“This remained the case throughout the entire project.”
In its overall conclusion, the review said: “Our review identified a collective failure from the parties involved. It is not possible to identify one single event which resulted in the errors as there were several contributing events.
“Additionally, there were a series of factors external to NHS Lothian which influenced and shaped the project which were not within the direct control of NHS Lothian. These factors contributed to the complexity.”
The report said a determining factor in the project was the decision, taken in 2010, to have twenty, four-bedded rooms.
It said three of these rooms were designed within critical care and therefore required different ventilation to achieve 10 air changes per hour but “this was missed from the outset of the project and remained unidentified until June 2019”.
Calum Campbell, chief executive of NHS Lothian, said: “We would like to acknowledge the extent of analysis that the chief internal auditor has undertaken, particularly the review of complex and significant documentation which relates to the project and spans 12 years.
“Recommendations in relation to decision-making, clarity, clinical engagement and involvement of external advisers have been made.
“Some areas identified have already been addressed and others will be implemented within the agreed time frames to ensure that future capital projects will benefit.
“The department of clinical neurosciences and children’s outpatient services have already settled into their new home and we are looking forward to the full opening as soon as possible.”
Conservative health spokesman Donald Cameron told BBC Radio Scotland’s Good Morning Scotland programme: “It’s a staggering revelation that a mistake on a spreadsheet sparked a chain of events that results in the delayed opening of this major hospital.
“It is both astonishing and appalling in equal measure. It must be one of the most costly errors in the history of the NHS in Scotland.
“And it is one thing for someone to have made this mistake in the first place but it is all the more shocking that it wasn’t spotted for so long, it took independent auditors to discover this early last year and it raises lots of questions.
“We need the answer to several questions – who was running these numbers? Who was checking these numbers? Why did no-one realise the error sooner? Who was monitoring the project? What Government oversight was there?”
A Scottish Government spokeswoman said: “The safety and wellbeing of all patients and their families is our top priority and should be the primary consideration in all NHS construction projects.
“A public inquiry is under way to help us understand the issues that affected both the Queen Elizabeth University Hospital campus site in Glasgow and the Royal Hospital for Children and Young People and Department of Clinical Neurosciences site in Edinburgh.
“It will also make recommendations to ensure that any past mistakes are not repeated in future NHS infrastructure projects.”
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