Patients and Relatives
Things have reached a pretty pass when an independent report into standards of care in the NHS needs to spell out simple, everyday things like 'effective communication' which hospital patients and their relatives have a right to expect all the time.
And if you ask me, the conclusions and recommendations in this chapter of the report are very weak and disappointing because they do not enhance the ability of patients and their relatives to make their voices heard if and when things are going wrong.
Patients and Relatives
11.8 Conclusion
The patient and relative group wanted to have a public inquiry because they wished a full examination of why there were so many deaths in which CDI was implicated. This group also wished to understand how the CDI problem had gone unnoticed for such a significant period of time. From an analysis of the evidence of relatives the two main areas of concern were personal care of patients and communication from both nursing and medical staff.
Relatives described serious deficiencies in communication on the part of both nursing and medical staff at VOLH. Communication on aspects of CDI was poor.
Relatives did describe incidents which raised significant concerns about the quality of nursing care in a number of wards. The evidence of patients with faeces under fingernails is of particular concern. Patients are entitled to expect to be clean and cared for when they go into hospital. This is a fundamental aspect of care. Some of the events described by relatives confirm the serious deficiencies found on detailed examination of patient notes by the expert witnesses, many of which are considered in Chapter 12. There should be no acceptance of a culture of poor care. It is important that standards are set and that these standards are enforced.
11.9 Recommendations
Recommendation 10: Health Boards should ensure that patients diagnosed with CDI are given information by medical and nursing staff about their condition and prognosis. Patients should be told when there is a suspicion they have CDI, and when there is a definitive diagnosis. Where appropriate, relatives should also be involved.
Recommendation 11: Health Boards should ensure that patients, and relatives where appropriate, are made aware that CDI is a condition that can be life-threatening, particularly in the elderly. The consultant in charge of a patient’s care should ensure that the patient and, where appropriate, relatives have reasonable access to fully informed medical staff.
Recommendation 12: Health Boards should ensure that when a patient has CDI patients and relatives are given clear and proper advice on the necessary infection control precautions, particularly hand washing and laundry. Should it be necessary to request relatives to take soiled laundry home, the laundry should be bagged appropriately and clear instructions about washing should be given. Leaflets containing guidance should be provided, and these should be supplemented by discussion with patients and relatives.
Palpable Nonsense (20 October 2014)
The RCN's knee-jerk reaction to a speech by Jeremy Hunt demonstrates how deluded the trade unions can be at times.
Because the greets health scandal of modern times, the premature deaths of up to 1200 patients and intolerable standards of care at Mid Staffordshire Hospital, occurred at a time when NHS resources were increasing significantly, year on year.
So the RCN's argument that mistakes and errors are down to 'understaffing' is completely laughable, if you ask me and Dr Peter Carter should be ashamed of himself for peddling such palpable nonsense.
The Royal College of Nursing says mistakes are the result of understaffed wards
Basic mistakes in hospitals in England cost the NHS up to £2.5bn a year, Health Secretary Jeremy Hunt is to say.
And the NHS could afford to hire more nurses if the errors were cut out, Mr Hunt will claim during a speech in Birmingham on Thursday.
Cost is incurred through problems like medication errors, avoidable infections after surgery, and litigation.
But a spokesman for the Royal College of Nursing said mistakes were the result of understaffed wards.
In his speech Mr Hunt will describe these kind of mistakes as "expensive and wasteful" at a time when hospital trusts are trying to save money.
'Picking up the pieces'
He will say: "I want every director of every hospital trust to understand the impact this harm is having not just on their patients, but also on their finances.
"And I want every nurse in the country to understand that if we work together to make the NHS the safest healthcare organisation in the world, we could potentially release resources for additional nurses, additional training, and additional time to care...
"More resources should be invested in improving patient care rather than wasted on picking up the pieces when things go wrong."
Basic mistakes in hospitals in England cost the NHS up to £2.5bn a year, Health Secretary Jeremy Hunt is to say.
And the NHS could afford to hire more nurses if the errors were cut out, Mr Hunt will claim during a speech in Birmingham on Thursday.
Cost is incurred through problems like medication errors, avoidable infections after surgery, and litigation.
But a spokesman for the Royal College of Nursing said mistakes were the result of understaffed wards.
In his speech Mr Hunt will describe these kind of mistakes as "expensive and wasteful" at a time when hospital trusts are trying to save money.
'Picking up the pieces'
He will say: "I want every director of every hospital trust to understand the impact this harm is having not just on their patients, but also on their finances.
"And I want every nurse in the country to understand that if we work together to make the NHS the safest healthcare organisation in the world, we could potentially release resources for additional nurses, additional training, and additional time to care...
"More resources should be invested in improving patient care rather than wasted on picking up the pieces when things go wrong."
Mr Hunt wants hospital trust directors to understand the financial impact of harm
A recently-published report commissioned by the Department of Health (DoH) described what it termed as "preventable adverse events" rather than mistakes, as costing the NHS "a significant amount of money".
It estimates the cost of such mistakes to be between £1bn and £2.5bn a year.
Last year the NHS spent £1.3bn on payouts after being sued by patients over care errors.
Four areas of poor patient safety highlighted by the DoH include falls and trips, bed ulcers, urinary infections caused by poorly fitted catheters, and deep vein thrombosis, which together cost an estimated £200m a year in extra care.
Mr Hunt's words will mark the start of a poster campaign warning staff about the financial problems basic errors cause.
'Not enough staff'
The health secretary is due to argue that it would be wrong to set targets or "issue a new ministerial decree" in an effort to cut out such problems - instead he favours a "cultural change" to make hospitals safer.
But Dr Peter Carter, chief executive of the Royal College of Nursing, said the government needed to invest in more staff before patient care can be improved.
He said: "Falls and preventable conditions such as pressure ulcers happen when there are not enough staff on a ward to care properly for every patient, not because nurses are unaware that these things should be prevented."
Labour have also argued that under the coalition government nursing numbers had fallen, and billions wasted on reorganising the NHS, which has resulted in care problems becoming more likely.
A recently-published report commissioned by the Department of Health (DoH) described what it termed as "preventable adverse events" rather than mistakes, as costing the NHS "a significant amount of money".
It estimates the cost of such mistakes to be between £1bn and £2.5bn a year.
Last year the NHS spent £1.3bn on payouts after being sued by patients over care errors.
Four areas of poor patient safety highlighted by the DoH include falls and trips, bed ulcers, urinary infections caused by poorly fitted catheters, and deep vein thrombosis, which together cost an estimated £200m a year in extra care.
Mr Hunt's words will mark the start of a poster campaign warning staff about the financial problems basic errors cause.
'Not enough staff'
The health secretary is due to argue that it would be wrong to set targets or "issue a new ministerial decree" in an effort to cut out such problems - instead he favours a "cultural change" to make hospitals safer.
But Dr Peter Carter, chief executive of the Royal College of Nursing, said the government needed to invest in more staff before patient care can be improved.
He said: "Falls and preventable conditions such as pressure ulcers happen when there are not enough staff on a ward to care properly for every patient, not because nurses are unaware that these things should be prevented."
Labour have also argued that under the coalition government nursing numbers had fallen, and billions wasted on reorganising the NHS, which has resulted in care problems becoming more likely.
Patients' Voices (5 June 2014)
Scotland's health minister, Alex Neil, made some sensible proposals the other day about strengthening the voice of patients in the NHS.
Now who could see anything problematic in that, but here's a terribly defensive response from one of the main health unions, the Royal College of Nursing (RCN), which sounds to me as if patients (or their families) say anything critical then the staff and the unions expect to consulted about what happens next.
Commenting on the announcement from Cabinet Secretary for Health and Wellbeing Alex Neil MSP that he will bring forward proposals for a new system of listening to, and promoting, the patients’ voice RCN Scotland Director Theresa Fyffe said:
“If we are to achieve an NHS in Scotland that truly focuses on patients, we need to listen to their concerns and give them the means for their voices to be heard. That’s why we supported the introduction of Patient Opinion into our NHS last year. We believe that all patients should be able to feedback their views on the care they receive, both positive and negative, so health boards and the Government can use this constructively to improve and change how things are done.
“At the same time, staff must also have a voice and be listened to. Patients’ views can affect already demoralised staff, who are trying to do their best under pressure. Health boards must therefore listen to what patients are saying and then listen and support staff to make the necessary changes to improve how care is delivered. Both patients’ and staff’s feedback and concerns are important and must be heard locally and nationally, if our NHS is to become ‘world class’.”
“If we are to achieve an NHS in Scotland that truly focuses on patients, we need to listen to their concerns and give them the means for their voices to be heard. That’s why we supported the introduction of Patient Opinion into our NHS last year. We believe that all patients should be able to feedback their views on the care they receive, both positive and negative, so health boards and the Government can use this constructively to improve and change how things are done.
“At the same time, staff must also have a voice and be listened to. Patients’ views can affect already demoralised staff, who are trying to do their best under pressure. Health boards must therefore listen to what patients are saying and then listen and support staff to make the necessary changes to improve how care is delivered. Both patients’ and staff’s feedback and concerns are important and must be heard locally and nationally, if our NHS is to become ‘world class’.”
Now this seems like a whole load of baloney to me because the NHS is one of the most highly unionised areas anywhere in the public sector and the staff already have a very strong voice and ability to express their views.
And as events at Mid Staffordshire Hospital have shown there have been terrible cases of neglect and poor standards of care within the NHS, so the problems are not always about staff working under pressure.
To my mind it's complete humbug to argue that "patients' views can affect already demoralised staff, who are trying to do their best under pressure" because what that sounds like to me is people getting their excuses ready without even listening to what patients and their families have to say.
Here's what Alex Neil had to say about his own proposals by the way and it doesn't seem to me that there's
“But let me be clear – there is absolutely no complacency and we will go on striving for improvement while staying true to the founding principles of our NHS.
“That is why we must do more to listen to, and promote, the voices of those we care for. We need the voices of our patients, those receiving care and their families, to be heard in a much clearer and stronger way. The introduction of Patient Opinion has provided a new and vital way to gather views.
“However, we will not stop there. That is why I will be bringing forward proposals for a new system of listening to, and promoting, the patients’ voice. I have tasked Healthcare Improvement Scotland and the Scottish Health Council to develop these new proposals.
“Their task is straightforward – develop a system that means we do more to truly hear the voice of patients.”
Nothing in that to get worked up or all defensive about if you ask me, but the RCN have form in this area as you can read below.
Voice For Service Users (5 March 2013)
Trade unions are experts at lots of things - especially at telling other people what to do and how to do it.
But in my experience trade unions are seldom keen to accept any critical assessment of their own performance or the kind of independent scrutiny - which operates routinely in many other areas of public life.
But in my experience trade unions are seldom keen to accept any critical assessment of their own performance or the kind of independent scrutiny - which operates routinely in many other areas of public life.
I wrote a post last month about the lack of leadership from the trade unions during the care scandal at Mid Staffordshire NHS Trust - in particular the largest nurses union, the RCN.
Royal College of Nursing
1.98 At Stafford, the RCN was ineffective both as a professional representative organisation and as a trade union. Little was done to uphild professional standards among nursing staff or to address concerns and problems being faced by its members.
1.99 A prime reason for this was a lack of effective representation from elected officers on site. Further, the support avaialable from RCN officials at a regional and national level was limited.
1.100 The RCN is not, of course, a regulator but a combination of a professional representative body and a trade union. However, it does represent a group of qualified professionals and seeks, as it should, to promote high standards of service and conduct. The evidence reviewed in this report suggest that the RCN has not been heard as might have been expected in pursuing professional concerns about the standard of care.
1.101 It appears there is a concerning potential for conflict of intersst between the RCN's professional role of promoting high quality standards in nursing, and its union role of negotiating terms and conditions and defending members' material and other narrow interests.
Ouch! - was probably the intitial reaction of the RCN to such devastating criticism of its role at Mid Staffs - and I suspect that the other NHS trade unions behaved in a similar fashion.
The lesson to learn is that NHS trade unions cannot champion the cause of services users and their families - who need a strong voice of their own to balance the many vested interests which control the NHS.
What's needed in the NHS and elsewhere in the public services is more People Power - and less control by the senior managers and bureaucrats who run the show at the moment - sometimes for their own selfish ends.
Hospital Trip Advisor (4 February 2013)
I am beginning to think that Dr Peter Carter - the chief executive of Royal College of Nursing (RCN) - is losing the plot.
The leader of the country's largest nursing union was in the papers at the weekend - making some rather extraordinary claims about poor standards of care in the NHS - and here's what Dr Carter had to say:
“Will there be another Mid Staffs? Yes, sadly there will be. There are 1.2 million people employed in the NHS and there is a hospital in every town. It would be foolish to say everything in the garden is roses.
Mid Staffs cannot be an isolated incident. The fact is, the service is under huge strain. Trusts are not thinking intelligently about how they deliver care and are simply cutting the numbers of frontline staff. Our members have a personal and professional responsibility to raise concerns.
The vast majority of patients still get good care, but that is no consolation to those who don’t. Mid Staffs has got this massive profile now, but there have been many others like it . . . Bristol Royal Infirmary, Basildon, Alder Hey. The report into Maidstone and Tunbridge Wells [where hundreds of patients died after an outbreak of the superbug C-difficile] is painful to read. On the wards there were beds that were eight inches apart ... what the hell were the managers doing, but also what was going on with the nursing culture? There was a culture of bullying and intimidation.
If the board had spent time walking the wards, talking to patients and staff, just doing their jobs, they may have saved hundreds of lives.
You wouldn’t expect staff at Kwik-Fit to get by with a bit of TLC and a bit of common sense. These are old people ... their bones are like porcelain, their skin is like tissue paper. They need highly skilled specialist care. The idea that four or five unskilled staff can take care of 30 elderly patients is nonsense.”
Now these comments come in advance of the report on Mid Staffordshire NHS Trust - where poor standards of care said to have caused up to 1,200 unnecessary deaths between 2005 and 2008.
So the first point to be made is that the scandal of Mid Staffs happened at a time of plenty for the NHS - which means that, broadly speaking, resources and money were not any part of the problem.
The second point I would make is that the NHS is one of the most highly unionised industries in the UK - and the RCN is one of the largest, most influential trade unions - with lots of RCN members in senior management and leadership positions.
In which case I fail to see how it can sensibly be argued that Trust's board members were somehow responsible for saving hundreds of lives - when there were all these staff around who were paid, some of them very generously as well, to look after patients.
I happen to think it would be a good for NHS board members to interact more with patients and their families - but surely this would be much more practical if the regulatory bodies in the UK made more unannounced inspection visits - and actually asked patients and families for their views on the standard of care received.
My mother died five years ago after and before she passed away my mum was a frequent visitor to her local hospital where - I think it's fair to say - that some of the care she received was very poor.
But no one asked my mum what she thought of her care - nor any of her family - which strikes me as very odd in this day and age - because feedback from patients and families is the obvious way to highlight underlying problems.
To paraphrase Dr Carter's own analogy - I think I receive much better customer care from Kwik-Fit than my dear old mum did at times - from her local NHS hospital.
A former health secretary in the last Labour government - Alan Milburn - came up with an interesting idea recently with his suggestion that the NHS needs an equivalent of Trip Advisor- so that patients and their families can provide useful feedback after a hospital visit.
People power meets patient power - now that really ought to be part of the answer.
Standards of Care (25 November 2014)
The BBC sets out a detailed report on the public inquiry which considered allegations about poor standards of care at the NHS Vale of Leven Hospital after an outbreak of Clostridium difficile (C.diff) in 2007-2008.
I plan to read the full report carefully, but the BBC summary makes clear that there were serious personal failures (by individual staff) as well as systematic failures (management and leadership) that ultimately were the responsibility of NHS Greater Glasgow and Clyde.
As a result the inquiry report contains the following, rather shocking, comment:
"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."
And that is why the NHS should never be put on a pedestal because services can fail just like anywhere else, if people let standards slip and don't do their jobs properly.
Vale of Leven C. diff inquiry criticises health board
The inquiry looked into the C. diff outbreak at Vale of Leven Hospital between 2007 and 2008
Scotland's largest health board has been heavily criticised by an inquiry into the country's worst Clostridium difficile (C. diff) outbreak.
The probe, led by Lord MacLean, looked into care at Dunbartonshire's Vale of Leven Hospital between 2007 and 2008.
Of the 143 patients with C. diff, it was a contributory factor in 34 deaths.
Lord MacLean said NHS Greater Glasgow and Clyde (GGC) had "badly let down" patients. The health board apologised unreservedly for a "terrible failure".
The judge 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."
He added: "There were failures by individuals but the overall responsibility has to rest with the health board."
Lord MacLean said "systems were simply not adequate to tackle effectively a healthcare associated infection" like C. diff.
He added: "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 was probably an underestimate as medical records were not available for all of the patients during the period in question.
He cited poor facilities, such as a lack of wash hand basins and a lack of commodes, as well as issues with the fabric of the building as evidence of poor management.
Scotland's largest health board has been heavily criticised by an inquiry into the country's worst Clostridium difficile (C. diff) outbreak.
The probe, led by Lord MacLean, looked into care at Dunbartonshire's Vale of Leven Hospital between 2007 and 2008.
Of the 143 patients with C. diff, it was a contributory factor in 34 deaths.
Lord MacLean said NHS Greater Glasgow and Clyde (GGC) had "badly let down" patients. The health board apologised unreservedly for a "terrible failure".
The judge 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."
He added: "There were failures by individuals but the overall responsibility has to rest with the health board."
Lord MacLean said "systems were simply not adequate to tackle effectively a healthcare associated infection" like C. diff.
He added: "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 was probably an underestimate as medical records were not available for all of the patients during the period in question.
He cited poor facilities, such as a lack of wash hand basins and a lack of commodes, as well as issues with the fabric of the building as evidence of poor management.
The five-year long inquiry was led by judge Lord MacLean
Report graphic on C. diff deaths
The judge said that prolonged uncertainty over the future of the Vale of Leven hospital contributed to poor morale and recruitment.
Management failures
Poor leadership among NHS GGC managers, the judge said, contributed to substandard nursing care and deficiencies in medical staffing.
He said inexperienced junior doctors had too much responsibility and consultants were stretched.
Lord MacLean also said antibiotics were prescribed in cases where it was inappropriate.
His report identified a number of failings:
The judge said that prolonged uncertainty over the future of the Vale of Leven hospital contributed to poor morale and recruitment.
Management failures
Poor leadership among NHS GGC managers, the judge said, contributed to substandard nursing care and deficiencies in medical staffing.
He said inexperienced junior doctors had too much responsibility and consultants were stretched.
Lord MacLean also said antibiotics were prescribed in cases where it was inappropriate.
His report identified a number of failings:
- governance and management failures within NHS GGC;
- inadequate attention given by NHS GGC and the Scottish government to reports about other C. diff outbreaks;
- significant deficiencies in the infection prevention and control practices;
- deficiencies in nursing care and medical care;
- lack of strong management.
'Repeated warnings'
Lord MacLean added: "An effective inspection regime, I am convinced, would have been able to identify the dysfunctional nature of infection prevention and control at the hospital.
"There must be an effective line of reporting, accountability and assurance.
"This was lacking for the Vale of Leven Hospital. In addition, repeated warnings over a number of years about the importance of prudent antibiotic prescribing had no impact."
C. diff Inquiry
- C. diff was a contributory factor in the deaths of 34 patients at the Vale of Leven
- C. diff is a bacteria which lives harmlessly in the gut of 10% to 15% of adults.
- It causes diarrhoea when the delicate balance of gut flora is disturbed, often following a course of antibiotics.
- It is easily spread via airborne spores.
- The inquiry into the C. diff outbreak at vale of Leven was delayed five times.
- The eventual cost of the inquiry is estimated to be just under £10m.
Lord MacLean acknowledged that improvements had been made since the C. diff outbreak.
He said: "NHS Greater Glasgow and Clyde did introduce more effective reporting systems for CDI (C. diff) after June 2008 but the message should be reinforced that systems must ensure that important information is relayed from ward to board (NHS GGC).
"I am convinced that the adoption of the recommendations proposed will result in a significantly improved focus on patient care, and in particular, care of patients who contract an infection such as CDI.
"Although it was the failures in how CDI was managed at the hospital that governed the work of the inquiry, the recommendations should, I hope, have a more far-reaching impact."
'Profound regret'
Andrew Robertson, chairman of NHS GGC, said: "On behalf of the board and our staff, I would like to offer an full and unreserved apology to the patients affected and to the families who lost a relative to C. diff in the months between January 2007 and late 2008.
"This was a terrible failure and we profoundly regret it.
"I can give the firmest of assurances that, as a result of the lessons that have been learned, this could not happen again."
Health board chief executive, Robert Calderwood, added: "Re-iterating my personal apology I hope the relatives can take some comfort that the lessons learned from this outbreak have resulted in significant improvements in clinical practice, for instance, in more prudent prescribing of antibiotics.
He said: "NHS Greater Glasgow and Clyde did introduce more effective reporting systems for CDI (C. diff) after June 2008 but the message should be reinforced that systems must ensure that important information is relayed from ward to board (NHS GGC).
"I am convinced that the adoption of the recommendations proposed will result in a significantly improved focus on patient care, and in particular, care of patients who contract an infection such as CDI.
"Although it was the failures in how CDI was managed at the hospital that governed the work of the inquiry, the recommendations should, I hope, have a more far-reaching impact."
'Profound regret'
Andrew Robertson, chairman of NHS GGC, said: "On behalf of the board and our staff, I would like to offer an full and unreserved apology to the patients affected and to the families who lost a relative to C. diff in the months between January 2007 and late 2008.
"This was a terrible failure and we profoundly regret it.
"I can give the firmest of assurances that, as a result of the lessons that have been learned, this could not happen again."
Health board chief executive, Robert Calderwood, added: "Re-iterating my personal apology I hope the relatives can take some comfort that the lessons learned from this outbreak have resulted in significant improvements in clinical practice, for instance, in more prudent prescribing of antibiotics.
Lord MacLean cited a lack of wash hand basins at the Vale of Leven
"These major improvements introduced since the tragic events of six years ago have made the Vale and all of our hospitals in Greater Glasgow and Clyde safer for patients than they have ever been."
In a statement issued by Thompsons Solicitors, families affected by C. diff at the Vale of Leven said: "There are no words we can say to you today that will accurately convey the anger, hurt and grief we have felt for the past seven years over the suffering that our loved ones endured as they succumbed to this terrible outbreak.
"Many of us watched completely powerless as our dearly loved family members died in distressing and degrading circumstances as hospital staff struggled to cope.
"We have reached the stage today after seven long years where Lord Maclean has identified many of the causes for the outbreak and has made recommendations which we sincerely hope will mean no other families will ever have to suffer the hell we have been through."
NHS 'shame'
The families said the 75 recommendations were "detailed and far reaching" and they expected the health authorities to "fully implement" them.
They added added: "The events at Vale of Leven that began in the late months of 2007 are a shame on the conscious of the Scottish NHS.
"We all believe in the NHS but our faith has been shaken to its very core. As a group will continue to fight until our campaign for justice for loved ones is satisfied.
"These major improvements introduced since the tragic events of six years ago have made the Vale and all of our hospitals in Greater Glasgow and Clyde safer for patients than they have ever been."
In a statement issued by Thompsons Solicitors, families affected by C. diff at the Vale of Leven said: "There are no words we can say to you today that will accurately convey the anger, hurt and grief we have felt for the past seven years over the suffering that our loved ones endured as they succumbed to this terrible outbreak.
"Many of us watched completely powerless as our dearly loved family members died in distressing and degrading circumstances as hospital staff struggled to cope.
"We have reached the stage today after seven long years where Lord Maclean has identified many of the causes for the outbreak and has made recommendations which we sincerely hope will mean no other families will ever have to suffer the hell we have been through."
NHS 'shame'
The families said the 75 recommendations were "detailed and far reaching" and they expected the health authorities to "fully implement" them.
They added added: "The events at Vale of Leven that began in the late months of 2007 are a shame on the conscious of the Scottish NHS.
"We all believe in the NHS but our faith has been shaken to its very core. As a group will continue to fight until our campaign for justice for loved ones is satisfied.
Bereaved families have called for the report recommendations to be implemented in full
"We are sincere in our belief that if we can prevent something like this from ever happening again then at least it will be a fitting tribute to their memories."
Newly-appointed Scottish Health Secretary Shona Robison also apologised to the patients and families affected, saying she was "truly sorry".
She said: "Our NHS failed in its duty of care for all of these patients and their families. As the cabinet secretary for health, that is a matter of deep regret for me, this government and indeed the whole of the health service.
"That is why we will accept all 75 recommendations and go further where we can. As well as creating our implementation group, I am today writing to all health boards to ensure they review their services against the report and respond to the government within eight weeks."
Ms Robison acknowledged that Lord MacLean's report had shown "a clear picture of the failings in the system that led to the C. diff outbreak".
These included a "lack of investment in the hospital, which was simply no longer fit for its purpose...a lack of managerial oversight and a fundamental breakdown in the links between what was happening at ward level and those in positions of authority at the board".
"The report highlights those who either abdicated their responsibilities or failed to carry them out effectively," Ms Robison said.
"There is no place for this conduct in our NHS, which fell below even the minimum standards we expect. It is for the health board as the employer to consider the implications and we would expect them to consider the report's findings on this aspect urgently."
"We are sincere in our belief that if we can prevent something like this from ever happening again then at least it will be a fitting tribute to their memories."
Newly-appointed Scottish Health Secretary Shona Robison also apologised to the patients and families affected, saying she was "truly sorry".
She said: "Our NHS failed in its duty of care for all of these patients and their families. As the cabinet secretary for health, that is a matter of deep regret for me, this government and indeed the whole of the health service.
"That is why we will accept all 75 recommendations and go further where we can. As well as creating our implementation group, I am today writing to all health boards to ensure they review their services against the report and respond to the government within eight weeks."
Ms Robison acknowledged that Lord MacLean's report had shown "a clear picture of the failings in the system that led to the C. diff outbreak".
These included a "lack of investment in the hospital, which was simply no longer fit for its purpose...a lack of managerial oversight and a fundamental breakdown in the links between what was happening at ward level and those in positions of authority at the board".
"The report highlights those who either abdicated their responsibilities or failed to carry them out effectively," Ms Robison said.
"There is no place for this conduct in our NHS, which fell below even the minimum standards we expect. It is for the health board as the employer to consider the implications and we would expect them to consider the report's findings on this aspect urgently."
Analysis, Eleanor Bradford, BBC Scotland health correspondent
The outbreak of clostridium difficile at the Vale of Leven hospital was one of several across the UK at the time.
Authorities often say that much has changed, but this time it really has. Levels of C. difficile are 75% lower than they previously were.
This has been achieved through better hygiene and infection control, but by far the biggest impact in Greater Glasgow was made through a change in the kind of antibiotics prescribed.
The relatives of those who became ill, or died, rightly want to know why these changes weren't in place earlier.
However, the public may end up asking a bigger question - whether it was worth £10m for an inquiry which took so long that by the time it reached its conclusions, the problem had already largely been fixed.
The health secretary noted that at the time of the outbreak, "there was no effective inspection regime at the time to pick up these failings".
"We now have an effective inspection routine through the Healthcare Environment Inspectorate that completes unannounced, comprehensive inspections and demands urgent actions," she said.
Ms Robison added: "Our top priority is that lessons are learned so that what happened at the Vale of Leven can never be allowed to happen again."
A full Scottish government response to the report will be published in spring 2015.
Jackie Baillie, the Labour MSP for Dumbarton, said the findings had "vindicated" the families who had called for a public inquiry.
"The C. diff outbreak at the Vale of Leven Hospital was the worst in the UK due to the high mortality rate," she said.
"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."
'Difficult reading'
She added: "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."
Scottish Conservative health spokesman Jackson Carlaw, said the report would be "extremely difficult reading" for those who lost loved ones.
He said: "Failing after failing is set out here, and there are very tricky questions for both the health board and the Scottish government."
Mr Carlaw said that as Scotland's new First Minister Nicola Sturgeon was health secretary from May 2007 she would "have to explain why the infection control and inspection regimes were so inadequate, and why the Scottish government wasn't paying attention to lessons being learned south of the border".
"We now have an effective inspection routine through the Healthcare Environment Inspectorate that completes unannounced, comprehensive inspections and demands urgent actions," she said.
Ms Robison added: "Our top priority is that lessons are learned so that what happened at the Vale of Leven can never be allowed to happen again."
A full Scottish government response to the report will be published in spring 2015.
Jackie Baillie, the Labour MSP for Dumbarton, said the findings had "vindicated" the families who had called for a public inquiry.
"The C. diff outbreak at the Vale of Leven Hospital was the worst in the UK due to the high mortality rate," she said.
"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."
'Difficult reading'
She added: "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."
Scottish Conservative health spokesman Jackson Carlaw, said the report would be "extremely difficult reading" for those who lost loved ones.
He said: "Failing after failing is set out here, and there are very tricky questions for both the health board and the Scottish government."
Mr Carlaw said that as Scotland's new First Minister Nicola Sturgeon was health secretary from May 2007 she would "have to explain why the infection control and inspection regimes were so inadequate, and why the Scottish government wasn't paying attention to lessons being learned south of the border".
Improvements have been made to care at the Vale of Leven following the C. diff outbreak
He added: "Many of the recommendations set out will already have been acted upon, and I'm sure NHS staff across Scotland are absolutely committed to an outbreak like this never being repeated."
Dr Charles Saunders, chairman of the BMA's Scottish public health committee, said the report was "uncomfortable reading for all of us involved in the provision of healthcare".
"Whilst we recognise, since the beginning of this inquiry, a number of steps have been taken to improve patient safety and the standards of care, it is important that the NHS and the Scottish government are not complacent.
"Some of the circumstances that led to the challenges which were experienced at the Vale of Leven Hospital still exist, and not just in small district general hospitals."
Unison regional organiser, Matt McLaughlin, said: "It is fair to say that NHS Glasgow and Clyde has now put in place systems that would recognise a similar trend were it to occur today and this is to be welcomed.
"However, the report also identifies many issues that are sadly not uncommon across Scotland and that our nursing members have been raising for a long time: short staffing, lack of equipment, wrong skill mix and little or no extra staffing when clinical needs on the ward change."
He added: "Many of the recommendations set out will already have been acted upon, and I'm sure NHS staff across Scotland are absolutely committed to an outbreak like this never being repeated."
Dr Charles Saunders, chairman of the BMA's Scottish public health committee, said the report was "uncomfortable reading for all of us involved in the provision of healthcare".
"Whilst we recognise, since the beginning of this inquiry, a number of steps have been taken to improve patient safety and the standards of care, it is important that the NHS and the Scottish government are not complacent.
"Some of the circumstances that led to the challenges which were experienced at the Vale of Leven Hospital still exist, and not just in small district general hospitals."
Unison regional organiser, Matt McLaughlin, said: "It is fair to say that NHS Glasgow and Clyde has now put in place systems that would recognise a similar trend were it to occur today and this is to be welcomed.
"However, the report also identifies many issues that are sadly not uncommon across Scotland and that our nursing members have been raising for a long time: short staffing, lack of equipment, wrong skill mix and little or no extra staffing when clinical needs on the ward change."
Reevel Alderson, BBC Scotland home affairs correspondent
Campaigners frequently call for a public inquiry to be held following a scandal or tragedy.
But only four have been held since the current law governing them was passed in 2005.
The problem for the government is that inquiries are costly and lengthy.
Lord Penrose's inquiry into the infection of blood for transfusions with the hepatitis C virus has yet to report, although it has reportedly cost £12m and has taken five years so far.
But public inquiries, which are chaired by a judge, are able to make recommendations which become legally binding.
During the ICL inquiry into the Stockline explosion, evidence about badly-maintained underground gas pipes prompted the Health and Safety Executive (HSE) to inspect other premises and issue enforcement notices.
In 2012 the Scottish government announced it would consult on improvements to the public inquiry system to make them more responsive, quicker and cheaper.
But nothing has so far been done.
