All Molly Cuddihy wanted was recognition of what she had gone through. That was what she told the Scottish hospitals inquiry in 2021, where she described the "frightening" fits and rigors she had suffered after contracting a bacterial infection at Glasgow's Queen Elizabeth university hospital while undergoing chemotherapy. "I was made sicker by the environment," the 19-year-old said in her evidence.
Molly had been 15 and revising for her National 5 exams when she was diagnosed with a rare bone cancer. She was treated at the Royal hospital for children and the adjacent QEUH, which are both part of a six-year public inquiry that reached its final stages and heard devastating new admissions this week.
"You had a critically ill teenager who could see what was materially wrong with the hospital building in 2018," said her father, John. He said the clinical care his daughter received was "world-class" - a sentiment echoed by all the families affected by this scandal - but "the basic principles of providing a safe and secure environment in which those clinicians could operate were simply absent".
After years of denial, NHS Greater Glasgow and Clyde finally admitted this week that serious infections in 84 child cancer patients, two of whom died, were probably caused by a contaminated water system at its flagship hospital.
The arduous delay in accepting what patients, families and whistleblowers had been telling hospital and health board management since the £842m super-hospital first opened in 2015 piled "avoidable distress and harm" on already suffering families, John says. "The fact that Molly never got to hear those words is even more painful."
Molly Cuddihy died last August, her organs irreparably weakened by the powerful drugs used to combat the infections as well as her cancer treatment.
For the past week, her father has attended in her stead to hear the concluding submissions to the public inquiry, which was ordered by the former Scottish health secretary Jeane Freeman after a number of deaths and high infection rates - as well as whistleblowers raising repeated concerns about infection control in its water and ventilation systems. Like other family members whose loved ones died or became seriously ill, John was left reeling by dramatic U-turns in the health board's position.
Another staggering 11th-hour admission was that the building was simply not ready to open when it did in April 2015 - just before the general election and with the SNP boasting about Scotland's biggest ever publicly funded NHS construction project.
The health board admitted that "pressure was applied to open the hospital on time and on budget" - despite tests carried out in December 2014 having highlighted the presence of microbes in the water supply - and that they did not have adequate staffing to maintain the sprawling new campus.
And having previously downplayed evidence from whistleblowers who repeatedly raised the alarm with managers, the board acknowledged this was "unfair".
Responding on Thursday, the three senior microbiologists who had tried to expose the failings pointed out that this belated and partial apology did not address the behaviour of senior management who had dismissed them as "attention-seeking" and "sensationalising" and failed to investigate their concerns "properly, openly or respectfully" for more than a decade.
The health board has insisted no individual should be held responsible for institutional failings.
As the week progressed, the families' shock at the latest admissions hardened into fury and, in a coruscating closing statement also delivered on Thursday, they described being "lied to, disbelieved, demeaned and smeared" by the health board.
Some of these were the first parents to have spoken out about the inadequate answers they got when they asked why their children were being given bottled water, or why their specialist paediatric cancer ward was suddenly shut.
"We cannot overstate the level of deceit and conniving cowardice displayed by GGCH during the whole unfolding of this awful scandal," they said. "As men, women and children fell ill and died, we were all told: There is nothing to see here."
They called for the past and present leadership of GGCH to "face a reckoning" and issued a chilling warning that "the QEUH is not a safe hospital" and "the current leadership of GGCH cannot be trusted to make it safe".
This echoed the whistleblowers, who said on the same day they still had "significant concerns" about the extent to which necessary changes had been instigated by senior management.
The Scottish Labour leader, Anas Sarwar, has described it as "the biggest scandal in the history of the Scottish parliament". He has suggested the cover-up goes right to the top, and this week he called for criminal investigations into Scottish government ministers responsible at the time, including Nicola Sturgeon and John Swinney.
Sarwar has campaigned for years alongside Kimberly Darroch, whose 10-year-old daughter, Milly Main, died in August 2017 after contracting an infection as she recovered from leukaemia treatment.
With the inquiry's final report anticipated later this year, other proceedings will continue: NHSGCC has been named as a suspect in a corporate homicide investigation looking into the deaths of Milly, two other children and a 73-year-old woman at the hospital campus; prosecutors are also investigating Molly's death.
At a ferocious session of first minister's questions on Thursday, Sarwar demanded that Swinney tell him "who applied the pressure and why" to open the children's hospital on the QEUH campus weeks after an internal report warned of high infection risk for immunocompromised children.
Swinney responded that the Scottish government had not been made aware until March 2018, but he committed to releasing any further cabinet minutes or ministerial correspondence and said he had "every confidence" that the inquiry chair, Lord Brodie, "will provide the open scrutiny and truth required by families and everybody else".
This week, NHSGCC's lawyer, Peter Gray KC, insisted that the health board was a "very different organisation" than the one involved in the design and construction of the hospital a decade ago, and he offered "an unreserved apology" on its behalf "for the distress and trauma experienced by patients and families during this time".
But John Cuddihy said it was too easy for the board to talk about change. "Where are the tangible outcomes? And if we make recommendations today, then who will be around to ensure that those are fulfilled?" he said. This is where he wants the Scottish government to step in, "so that this never happens again".
"What Molly said very clearly, and it was read out at her funeral, was that the clinicians treated her as somebody who counted," he said. "When it came to the institution, they didn't see her. And that was the most hurtful thing for Molly. She wasn't looking to apportion blame to any one individual. She just wanted them to recognise what had happened because that enables you to implement meaningful change."