To: The Scottish Courts and Tribunals Service

1.    NHS Greater Glasgow and Clyde, being a party to whom a recommendation under Section 26(1)(b) of the 2016 Act was addressed, responds to that recommendation as follows:

2.    NHS Greater Glasgow and Clyde was a participant in the Inquiry into the death of Sophia Evangeline Smith, who died on 11 April 2017 within the Neonatal Intensive Care Unit at the Royal Hospital for Children in Glasgow, aged 12 days. 

3.    In her determination, the Sheriff made a recommendation which stated:

“Weekly screening of vulnerable neonates in intensive care is a useful early warning of Staphylococcus aureus colonisation. This can inform clinical decisions with regard to possible infection and antibiotic therapy. NHSGGC should review the existing protocol in order that it is properly complied with at all times. Other Health Boards should consider adopting a similar screening process.”

4.    The Inquiry had heard evidence of the existing protocol in place within the Neonatal Intensive Care Unit at the Royal Hospital for Children in Glasgow at the time of Baby Sophia’s death whereby babies are subjected to weekly swabs, similar to those taken on admission. Such swabs are capable of detecting Staphylococcus aureus colonisation. 

5.    NHS Greater Glasgow and Clyde offers its assurance to the Inquiry that the recommendation directed to it is being addressed. An existing action to review the operating procedure for neonatal microbiology surveillance, taking account of Health Protection Scotland’s evidence-based screening guidance, was agreed by NHS Greater Glasgow and Clyde in advance of the Inquiry. This is ongoing and, in view of the recommendation of the Inquiry, will be completed before the end of 2025.

6.    Further, NHSGGC notes Recommendation 2 of the Inquiry. For itself, NHSGGC has shared the learning from Dr Coutts at board level across its hospitals. The Inquiry considered that those matters as set out in Recommendation 2 ought to be disseminated at national level. On Recommendation 2 being brought to its attention, Public Health Scotland has advised NHSGGC that, whilst it has an interest in the community risks associated with PVL-MSSA, it would not have insight into the clinical risks associated with the infection, nor the difficulties of diagnosis, methods of treatment and the learning as described by Dr Coutts in evidence, as it has no remit in relation to advising on clinical practice. 

7.    It is considered that the more appropriate route to share the information identified by the Inquiry on a national level would be through the Scottish Perinatal Network to all neonatal consultants. To that end, a Situation, Background, Assessment and Recommendation (SBAR) will be produced by NHSGGC to highlight the information and learning of Dr Coutts. This will be circulated by NHSGGC via the Scottish Perinatal Network in order that this learning is shared fully at national level with neonatal consultants.