 We have a estatment by Jean Freeman on the infection incident at Royal Infirmary in Edinburgh. The cabinet secretary will take questions, as usual, after a statement. I would encourage members to press their request to seek buttons if they wish to make a contribution. I call on the cabinet secretary. I am grateful for the opportunity to update members on the actions taken by NHS Lothian in response to an infection incident at the Royal Infirmary of Edinburgh. On 19 March, NHS Lothian wrote to all patients who had aortic valve replacement operations in the six-month period between September 2018 and March 2019 to advise them of a low infection risk arising from their surgery. Those precautionary letters, which were sent to 186 patients, were triggered by the following events. On 19 February, we were advised by Health Protection Scotland through the normal channels of a patient who had contracted a mould infection and who had undergone cardiothoracic surgery at RIE. On 20 February, NHS Lothian established an incident management team to investigate this matter and set the healthcare infection incident assessment tool at red due to the severity of the illness and public concern. NHS Lothian followed this on 26 February by, rightly, instigating a retrospective review of all patients over an 18-month period. From that exercise, 186 patients were identified for whom there was a low infection risk. Measures were put in place to contact these patients by letter and to provide them with contact information to use for any follow-up questions that they had on receipt of the letter itself. To date, a total of 26 patients who have received letters have contacted NHS 24. 19 of those patients have been passed on to the board for further discussions. Additionally, information has been provided to local GPs and to cardiologists regarding symptoms to be aware of and guidance on appropriate testing and onward referral should that be needed. Turning to the infection itself, three types of mould infection have been identified, which have affected six patients. Sadly, some of those six patients have died. No further cases have been identified since November 2018, but I know that the whole chamber will join me in offering our sympathy and condolences to the families and friends that have been affected. The three types of mould that have been identified are Lychymere, Cormbifiria, ExoFailure, Demetates and Expergillus. None are commonly found in hospitals. NHS Lothian proactively undertook an extensive investigation of this incident and, as they should, sought the help of Health Protection Scotland, who have visited the hospital at the board's request and is providing comprehensive expert support to them. The detailed investigation is being undertaken by the lead infection control doctor, together with NHS Lothian's director of operations and director of technical service. Health Protection Scotland have visited the wards and theatres involved. A comprehensive question set relating to ventilation within the cardiothoracic theatres was devised by the lead infection control doctor, the lead infection control nurse, with some additional questions from Health Protection Scotland. The response to those questions has satisfied the infection control team and the director of facilities that the ventilation within the theatres concerned is operating within acceptable parameters in terms of air pressures, air changes, air flow and no concerns are noted relating to filters. In addition, NHS Lothian has implemented the further steps that we would expect to minimise the risk of further infection spread, including additional and specialised cleaning and environmental decontamination with hydrogen peroxide vapour in all relevant wards and theatres, a review of practice and air and water sampling from both the environment and specialist equipment. As a precaution, four planned elective surgeries at the hospital were cancelled last week to allow for these additional preventative measures to be carried out. Elective operations recommenced on 26 March in two of the four theatres subject to this additional preventative work and the other two will be operational when the additional cleaning, air sampling and other measures have been completed. All patients whose operations were cancelled have now had their operation rescheduled over this week and next. Presiding Officer, I completely understand that for patients who have been contacted by the board, this will have been a worrying time. Let me repeat, the board was right to undertake a review of cases and to inform patients that they are identified as a result of that exercise. Those precautionary steps were the right ones to take, designed to minimise risk and to provide a clear pathway for those with concerns to access services as easily and efficiently as possible. Presiding Officer, this is the right time for me to say again that in Scotland we have learned valuable and wide-ranging lessons from the tragic experience at the Vale of Leven hospital over a decade ago. It is important to recognise the significant improvements in patient safety that have been made and sustained in those 10 years. Healthcare-associated infection outbreaks are rare and, although it is important to respond when they do occur and to recognise that they are of critical importance to the individuals and the families affected, they do affect a very small proportion of the 1.2 million inpatient and day cases that are treated every year in Scotland. With the introduction of the national infection prevention and control manual, assessment, reporting and escalation of outbreaks is a far more robust process. Infection prevention and control teams undertake active surveillance of certain organisms and can therefore identify outbreaks after finding just one or two cases. As part of outbreak investigations, boards undertake active case finding to look for cases retrospectively and prospectively. The current precautionary steps undertaken by NHS Lothian resulted from an extensive review of the records of thousands of patients who had many different types of surgery carried out since the beginning of 2015. That demonstrates a rigorous approach by NHS Lothian to ensure patient safety. Overall, the board has a strong record. Figures published on 12 February this year show that their hospital standardised mortality ratio fell by 2 per cent at the Royal Infirmary of Edinburgh, 10.4 per cent at the western general and 13.6 at St John's over the four-year period of January to March 2014 to July to September 2018. In addition, NHS Lothian has seen steady reductions since 2014 in both stafococcalus eras, bloodstream infections and C. diff infection. As regards infection associated with caesarean section and hip atheroplasty, NHS Lothian is on a par with the rest of Scotland. In terms of positive results from MRSA testing, since 2007, NHS Lothian has seen a 98 per cent decrease, comparing well to the 93 per cent decrease for Scotland overall. Clearly, there are processes that we can improve to make our hospitals as safe as they can be, which is what the Scottish public has every right to expect. As my colleagues on the Parliament's Committee for Health and Sport have recently noted, there are lessons for us to learn from the recent incidents in Greater Glasgow and Clyde, particularly the importance of robust communication between infection prevention, control and estates staff. That is especially important during maintenance or repair work of the NHS Scotland estate when extra control measures need to be put in place to reduce the risk of infection. When I updated Parliament on 26 February, I announced that I had commissioned an independent review to look at the design, build, commissioning and construction, handover and on-going maintenance at the Queen Elizabeth University hospital and how those matters contribute to effective infection control. In order to ensure appropriate membership of the review committee, the independent chairs of the review, doctors Brian Montgomery and Andrew Fraser, have been taking advice from experts on who will best be able to contribute, as well as analysing and reflecting on the work that has been done to date. From that, they will determine the precise remit of the review and the resources and support that they will require. We expect the independent chairs to consult on a draft remit shortly. In addition, we are strengthening the roles that NHS Scotland individual infection prevention and control team members play and the expert service that they provide. Next week, to provide further reassurance of the efficacy and robustness of our approach, our chief nursing officer will meet board healthcare-associated infection leads to reinforce their responsibilities in terms of infection prevention, emphasising the mandatory surveillance requirements contained within the national infection prevention and control manual and ensuring that boards have local mechanisms in place to ensure that the manual is reliably and sustainably implemented in their board. In conclusion, I recognise that no patient wants to receive a letter similar to those sent by NHS Lothian last week, but I hope that what I have outlined today provides reassurance that those letters form part of a proactive, precautionary infection control and risk management system here in Scotland. Not all healthcare-associated infections are preventable, but we have dedicated professionals and a rigorous system focused on limiting and controlling them, a system that is alert for potential infection risks, how to assess and manage those risks and a system that consistently looks to improve. Miles Briggs, to be followed by Monica Lennon. I thank the cabinet secretary for advance sight of the statement. As a Lothian MSP, I know from concerned constituents who have contacted me and their families just how hard this has been. I would like to start by sending my sympathies to the families and friends of the six patients who have been infected or who have died, as well as 186 patients who have been contacted as a precaution. Can I therefore ask the cabinet secretary in terms of moving forward around this case what plans does the Scottish Government have to review biological infection prevention as part of the patient safety initiative in light of the cases that we have seen across NHS Scotland? Will the cabinet secretary also look to review how this Parliament is updated on such cases when they occur and outbreaks across Scotland, like we have seen over the past few months? It is quite clear that public confidence has been shattered recently in our NHS estate and it is something that we need to all work to address. I think that that is something on a cross-party basis in this Parliament. I hope that the cabinet secretary will also look to take forward. I am grateful to Mr Briggs for his question. In terms of the important first part of your question about what more can we do in terms of patient safety in looking at those unusual infections because they are, I have asked the national clinical director to begin some work looking at where we might find international information and expertise and whether or not it is the case that these infections always existed but were masked by MRSA, Cdifusail, et cetera. As we have successfully bring those ones down, which we have done and that needs to be recognised, then these small outbreaks of these others, critical though they are because of the impact on patients, emerge. We need to understand them better and know more about them. Also know not only what might trigger their occurrence but how we can prevent them. I think that it is a really important point. I am very happy as that work progresses to ensure that the Health and Sport Committee, because I think that that would be the right place, is kept advised of what we are doing to progress that look. You would expect that it might take some time, but we will keep you up to date. In terms of the wider question about updating Parliament, I think that it is, again, a very fair point. I have tried to do that, partly by always responding positively when statements are asked for or initiating those myself using the GIQ process and writing to the committee as appropriate. I am very happy to talk with the Opposition Party spokespeople about what more you might think I can usefully do in that regard. If members are content with that, we will organise just such a discussion. Monica Lennon, to be followed by Andy Wightman. Thank you. I thank the Cabinet Secretary for Advanced Sites of her statement. On behalf of Scottish Labour, I offer our condolences to the families of the people who died after contracting mould infections at the Royal Firmary of Edinburgh. We recognise who it is also very distressing for the staff at the hospital. Unfortunately, here we are again. It is a different hospital, a different city, different infections, but the outcome is the same. Patients have died and public confidence continues to dip. The Cabinet Secretary rightly mentioned the Queen Elizabeth University hospital as well as the lessons from the really leaving outbreak of 10 years ago. None of us wants to learn of any further tragic outbreak no matter how rare or how few patients are affected. I ask the Cabinet Secretary what actions she has taken personally since taking up her post to ensure that routine monitoring in all of our hospitals is as excellent as it can be, in particular to protect vulnerable patients from those potentially fatal infections. I am grateful to Ms Lennon for her question. I think that it is important to say, of course, that we all want to see the minimal infection outbreak in any of our healthcare settings, whether it is acute community, health and social care, whatever it might be. I am sure that that is shared with Ms Lennon, Mr Briggs and others. My complete focus, patient safety, is the most important thing that any Cabinet Secretary can focus on. However, we need to accept, too, that not all healthcare infections are preventable. Some emerge that are resistant to existing medication and a resistant form of treatment. To some extent, although our medical advances are exemplary and much to be acknowledged globally, there are times when we are playing catch-up to how infections and bugs work to be resistant to antibiotics, for example. In terms of my personal involvement in that, I have, of course, as you will know, I am very happy to set out a full list for Ms Lennon, but I have, as you know, tasked the previous director general and the current one with direct contact with directors of estates, work with infection control leads. We have a regular update on all of the issues that the chamber is aware of. We have raised it with chief executives at every meeting. I have raised it with the chairs. We have made paid particular attention to the question of maintenance and estates and continue to do the work on that. Again, we will update the chamber on that. That is a constant part of the job that I am doing because it matters so much. Andy Wightman to be followed by Alex Cole-Hamilton. I thank the cabinet secretary for advance sight of her statement. I also wish to associate myself and Scottish Greens with her remarks on offer sympathy and control into the family's affected. Health Protection Scotland says that it is essential that lessons are learned from outbreaks. It is not clear to me what lessons are to be learned from this. First, on a point of clarification, in her statement, I heard the cabinet secretary right when she said that none of those moulds are commonly found in hospitals. The written statement that she circulated in advance says none are not commonly found. I wonder if she could just clarify that, in fact, those are unusual moulds and her oral statement was, in fact, the correct one. Finally, her statement indicates that acceptable parameters were found in the hospital and that preventative work was undergone. However, no where in her statement did she actually indicate why those moulds were found in an operating theatre and I am wondering if we know why. Thank you very much and I thank Mr Wightman for that. Can I just correct? There was a double negative in the written statement and he is correct. What I said is the right thing. Those are uncommon and not found in hospital environment infections, which is part of what lies behind Mr Briggs' question about if this is unusual, what is happening here. That also takes us to the point about Mr Wightman's first part of his question about what lessons are to be learnt from this. One of the lessons is that we need to investigate further. Given that those are unusual and not found in acute settings, then why has this happened here and what is the exact nature of this? In terms of the source, so far the source has not been identified. That is why, in my statement, I made the point about the ventilation system and the work that had been undertaken in the ventilation system. The normal process that an infection control team goes through to identify source, looking at where there is commonality if the more-in-one patient has been accepted in terms of healthcare staff or equipment or location has not produced a source. We continue to search for that. The lessons from it are in part any improvements that can be made to the operating manual. Once we have identified the source, there will be lessons to be learnt from that, ensuring that we continue to be robust across all our boards in the application of that national manual, which is precisely why the chief nursing officer is taking the additional action that I outlined in my statement. All those are continuous lessons, and of course we have learned that we need to pay very close attention to the quality of the engagement between estates, maintenance and facilities and infection prevention and control. We are checking and looking to make sure that all of our boards are learning those lessons. There are always lessons to be learned, and we are keen to make sure that that is always the case, and despite the overall good record in infection prevention and control across the NHS Scotland, complacency is never allowed to slip into this and think that we have this exercise covered because there is always more that we can do. Alex Cole-Hamilton, followed by Emma Harper. Thank you very much, Presiding Officer. Can I associate those benches with the remarks of sympathy to those affected? 186 letters have been sent out in total, but only 26 patients have proactively contacted NHS Lothian. Is the cabinet secretary confident that everybody has received and understood the risks associated with the infections to which they have been exposed? On the question of mould, I understand that she cannot say where the source came from, but can she say where those moulds are commonly found? Are they domestic moulds, agricultural moulds, and will that help her in the investigation to follow? Cabinet secretary. On the latter part of the question where are those moulds commonly found, that is part of the work that is going on at the moment to try and help us then if we can do any more in terms of the investigation to look at where they might be, how they might have reached that acute setting. In terms of the numbers of people who have so far responded out of that 186, I have asked the board to provide me assurance about how sure they could be that everyone did receive those letters. I think that there is a fairly straightforward way of doing that, so I am expecting them to return to me with that information. I am very happy to make Mr Cole-Hamilton aware of that when I have it and indeed other members. The understood part is difficult, but many of those patients will have continuing appointments with either their GP for the issue from which they had the operation in the first place, or from the consultant concerned. That is why we made sure that our cardiothoracic consultants across not just this board, there may be some patients who had their procedure in Lothian, but they come from another health board, but also all GPs are aware of this issue, aware of the symptoms, aware of the systems that have been put in place to assist any of the 186, so that they can continue to raise that with patients as they come before them. I am not sure if there is more that we could do in that regard, but I am very happy to look to see if there is should anything be suggested. All the parties in front benches have asked the question that there are nine members who wish to ask a question. There are six and a half minutes left, so very short questions and succinct answers, please. Emma Harper is to be filled by Jeremy Balfour. Thank you. Can the cabinet secretary outline whether the whistleblowing process at NHS Lothian would have helped with this investigation of infection incident? Can she provide an update on the plans to appoint an independent national whistleblowing officer in Scotland? Cabinet secretary. I am not sure if the whistleblowing process at NHS Lothian would have assisted the board infection control, which is proactive, as I described, identified this very early on. Of course, in other cases, whistleblowing has been of assistance in these matters. In terms of where we are, we are finalising the work with SPSO, who will take on this role to ensure that we are absolutely ready. In the next few weeks, I intend to outline a series of measures, most of which members are anticipating on all the actions that we need to take on whistleblowing and the result of the review in Highland. Jeremy Balfour, to be filled by Colin Beattie. I note from the cabinet secretary that two operating theatres are still closed. I also note that, as she said, all patients in regard to these procedures will be seen within the next two weeks or so. Have other operations have to be cancelled because these two theatres are down? If she does not have information, could she provide how many operations have been cancelled as a result of the two theatres being closed? Cabinet secretary. The total number of operations cancelled as a consequence of this infection were four. All those four cancelled operations have been rescheduled, as she said, this week and next week. The two theatres that have yet to reopen will be reopened as soon as the additional work that was done in the first two is completed in the second two. All the other rotas to ensure elective surgery continues as well as emergency surgery have been redone to accommodate that downtime, if you like, in those facilities. As soon as we have the date for the reopening of the second two theatres, we will make sure that members are aware of that. Colin Beattie, to be filled by David Stewart. Can the cabinet secretary confirm that all clinical staff who are responsible for infection control receive on-going training in line with best practice? Cabinet secretary. Yes, I can. All Scottish health and social care staff and students have access to the Scottish infection prevention control education pathway. That is part of their continuous development and their learning. It is the job of the board and, indeed, clinical managers inside the board to ensure that everyone is keeping their learning up to date. David Stewart, to be filled by Sandra White. Thank you, Presiding Officer. Are there any plans in place that could pick up invasive fungus-like materials such as cryptococcus in hospital ventilation systems before patients become infected? Cabinet secretary. That is part of the work that Greater Glasgow and Clyde are currently looking at in trying to identify how that infection entered a closed ventilation system, which is what they rightly had, and then produced the results that we have discussed previously. Greater Glasgow and Clyde are undertaking that work. Health Facility Scotland are involved with them in doing that. That will be part of what the independent review, of course, looks at. That will include whether or not there are additional preventative measures if you like in the external fabric of a building that can be introduced in order to prevent any infection coming from something like pigeon droppings into what should be the safest of all systems inside the hospital. Sandra White, to be felt by Gordon Lindhurst. Thank you, Presiding Officer. Cabinet secretary mentioned that the three types of mould are very uncommon in hospitals. We also know that Scotland has a strong record in infection control. Can I therefore ask the cabinet secretary how Scotland compares with other countries in terms of benchmarking infections control and if any lessons can be learned from other countries regarding the type of infection? Cabinet secretary. Thank you for that. The 2016 point prevalence survey demonstrated that Scotland has the lowest prevalence of healthcare-associated infections within the UK and Southern Ireland. In terms of the rest of Europe, Scotland also compares favourably to France, Italy, Spain, Portugal, Greece and Finland. That is of some assurance. However, today in Glasgow a three-day conference begins where Glasgow has secured that. It is the largest event of its type over 24 such conferences over 24 years where over 3,000 delegates are coming together from 70 countries to talk about the international learning that we need to be part of to continuously improve our practice. We are engaged continuously in looking at what more can we learn and what more can we do. Gordon Lindhurst, to be followed by David Torrance. Can the cabinet secretary confirm regarding the 186 letters what follow-up support has been provided by NHS Lothian and also what steps have been taken to make sure that individuals have actually received the letters? Cabinet secretary. I think that the last part I've already answered in terms of Mr Cole-Hamilton's question. In terms of follow-up, the letter sets out the basis on which the individual has been written to the low infection risk that they may be subject to what are the symptoms that might indicate that and directs them towards NHS 24, NHS Inform in the first instance for any questions that they might have but also advises them that their GP and their consultant is alert to this and so when individuals make that contact as we've outlined in my statement then the board is following that up. That is the right protocol there is a really clear protocol about how patients are advised of this kind of situation and that is that it should always be in writing it should never be by telephone for example so the board has done exactly the right thing and then is following up where people get in touch with them but also as I explained to Mr Cole-Hamilton those individuals those 186 people will have follow-up appointments with their GP or with their consultant and again that will be raised with them so to make sure that they understood what the letter said and that they are asked about any potential symptoms they might have. David Torrance Thank you Presiding Officer Can the cabinet secretary confirm what health agencies are working together to support NHS Loving Cabinet Secretary NHS Lothian rightly and directly involved Health Protection Scotland are working with them to provide expert advice they've also visited the theatres and the wards concerned in addition NHS Lothian is in touch with the expertise inside Scottish Government and the health directorate and will make use of health facilities Scotland in terms of any changes that once the source is identified may need to be made to the infrastructure at the Royal Infirmary of Edinburgh but I should stress at this point there is no indication of any changes required to that internal infrastructure Thank you and that concludes our statement apologies to George Adam and Neil Findlay we have run out of time but we'll move on now to portfolio questions just a few seconds for the ministers and members to change seats