Health boss 'dumbfounded' by hospital's woes
The man in charge of NHS Lothian said he was left "dumbfounded" at the missed opportunities to spot the problems in Edinburgh's new children's hospital.
Tim Davison said the last-minute delay to the opening of the new Sick Kids site came as a "huge shock" and said he considered quitting.
But the NHS Lothian chief executive said a collective failure of "many senior and expert staff" was to blame.
It will be next autumn before the new facility will open.
Mr Davison promised staff and patients they could be "confident" the new target opening date would be met but he admitted a review of why things went wrong was needed.
He said: "In July we believed this hospital would be compliant and it came as a huge shock to find, just before we were moving, that in some respects it hadn't reached the compliance we expected it to.
"We now know what happened, we now need to understand how that happened because it seems unbelievable that so many senior people would collectively, and individually, fail to spot this."
An independent review of the governance arrangements for the new hospital found that the main issue with ventilation in its critical care units stemmed from an error in a document produced by NHS Lothian at the tender stage in 2012.
It found that this was human error relating to confusion over interpretation of building standards and guidance, and that opportunities to spot and rectify the error by IHSL, the private consortium with the contractual responsibility to design and construct the hospital, were missed.
He said: "We remain dumbfounded really as to why so many senior and expert staff collectively did not pick up on these opportunities but I think the independent review made it clear there was no single person or single incident to blame."
Repayments for the hospital building - the equivalent of about £1.4m a month - to IHSL started when NHS Lothian moved into the hospital in February.
IHSL has pointed out that its works on the hospital were signed off as complete by an independent certifier on 22 February before the health board moved in.
Mr Davison continued: "I have considered my position very, very carefully. This is probably the biggest issue that I have had to deal with in almost 37 years in the health service but I believe I have acted entirely appropriately and professionally throughout."
Confusion over interpretation
Mr Davison pointed out that NHS Lothian had spent about £1m on its own plans for a new children's hospital before the Scottish government decided the project would be done under the Non-Profit Distributing (NPD) system, the Scottish government's version of controversial private financing models such as PFI.
This means the new facility cost about £150m to build, but its full price tag over the next 25 years, including maintenance and facilities management fees, will be £432m.
IHSL has the legal responsibility to design, build, finance and maintain the new hospital but NHS Lothian shared its original plans with the consortium "as an aid rather than a formal contractual document" and Mr Davison suggested this might have been a factor in the confusion over interpretation of building standards and guidance for the hospital's ventilation.
A spokesman for IHSL said: "The works on the hospital were signed off as complete by the independent tester on 22 February when we handed over the building into the possession and operation of NHS Lothian.
"We continue to work with NHS Lothian to facilitate migration to the new hospital on the timetable set out by the Scottish government. Once open, the hospital will provide the community with access to a world-class facility that meets the needs of patients and a modern healthcare system."