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THE WATT GROUP REPORT
CHAPTER 1 INTRODUCTION
Following the outbreak of salmonella in the Victoria Infirmary, Glasgow, a Group under the chairmanship of Dr Brian Watt was set up by the Scottish Executive to review the outbreak, with a remit to:
(a) "Review the circumstances surrounding the onset of the outbreak of salmonella infection at the Victoria Infirmary, Glasgow, in December 2001 and January 2002 and identify the likely causal factors;
(b) Assess the management of the outbreak and its effectiveness in reducing further exposure to the organism involved;
(c) Assess how the NHS Trust managed the overall situation, including communications with other relevant organisations and the public; and
(d) Draw conclusions and make recommendations to help reduce the risks of future outbreaks of infections of this kind in hospitals and help improve both outbreak and overall management."
The Group convened during May 2002 and met a wide range of individuals from all of the relevant organisations involved. As far as possible, the Group as a whole interviewed each individual. The Group also interviewed staff from the Scottish Executive; in these latter interviews no secretariat was present and members of the Group took notes. Membership of the Group is given in
Appendix A and a list of individuals interviewed is given in
Appendix B.
Where opinions are expressed on various issues covered in this report these are based on: interviews; professional opinion; the relevant guidance listed in
Appendix D; and the review of a large series of relevant documents, some confidential. A full list of the non-confidential documents is given in
Appendix C. Access to these documents can be obtained by contacting:
Mr John Brunton, the Scottish Executive Health Department, St Andrew's House, Regent Road, Edinburgh EH1 3DG, Tel: 0131 244 2868.
Fatal Accident Inquiry/Investigations by Health and Safety Executive
At the time of writing the Report, decisions on whether to proceed to a Fatal Accident Inquiry had not been made. Also, an investigation by the Health and Safety Executive was continuing. The Group was given permission by the Procurator Fiscal to proceed with their review, and to receive a confidential briefing from the Health and Safety Executive to assist in their work. This briefing also informed the opinions of the Group.
The Group's Approach to the Review
From the beginning the Group worked on the basis of 3 principles:
(1) The purpose of the Review was not to apportion individual blame, but to identify systematic shortcomings and to make recommendations;
(2) The Review would not be a "white-wash"; where shortcomings were identified, these would be clearly outlined, irrespective of where they occurred; and
(3) All comments made to the Group during the interviews would be non-attributable.
These principles were explained to each individual before their interviews.
The Group preserved patient confidentiality; the patients involved were known to the Group, and are referred to in this Report, by letters only.
At the request of the Group, the Trust wrote to the relatives of the bereaved patients giving them the opportunity to meet the Group if they wished.
Acknowledgements
We are very grateful to all of those who took part in interviews. We are especially grateful to Dr Giles Edwards and Mrs Emily Simpson (Information Librarian, Royal College of Physicians, Edinburgh) for help with literature reviews.
We are very grateful to our Secretary, Mr John Brunton, for his clear minuting of the interviews, collation of documents and organisation of the administrative arrangements.
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