The Sunday Post, 26 November 2023, by Marion Scott.
Health campaigners are accusing NHS officials of failing to comply with rules over the investigation of hundreds of serious incidents which harm or kill patients.
A shake-up of the rules surrounding the publication of such incidents in the wake of the NHS Ayrshire & Arran baby deaths scandal mean since 2020, the NHS has been required to comply with a new Serious Adverse Event Report (SAER) framework.
Overseen by Jason Leitch, National Clinical Director of Healthcare Quality and Strategy, the rules mean health boards are required to report and publish serious incidents of harm and death. Drawn up by Healthcare Improvement Scotland, the rules also require boards to share the un-redacted outcome of investigations with the families of patients and staff, as well as publishing “learning” so mistakes are not repeated.
But not all are fully complying despite the number of serious harm incidents in Scotland rocketing by around a third, from 466 in 2020 to 626 last year. Rab Wilson, the health campaigner whose whistleblowing over the NHS Ayrshire baby deaths scandal led to the shake-up of the SAER system, said: “I fought for greater transparency so patients would be safer, but the so-called reform has been nothing short of a disaster.
“Instead of making things safer, 10 years on, the figures tell a very disturbing story. Things are far worse now.”
We can reveal not all of the worst NHS blunders are even being included in the figures, such as mental health nurse Neil Alexander, 64, who died along with a patient when Covid swept through his Ayrshire hospital ward, also infecting 20 other staff and patients in 2021. Or the death of one of Nicola Sturgeon’s top advisors, Andrew Slorance, 49, who died from coronavirus while being treated for cancer at the Queen Elizabeth University hospital in Glasgow.
His widow Louise says it is “unacceptable” that Andrew’s death “did not warrant” an SAER investigation, according to NHS Greater Glasgow & Clyde. Mum of five Louise said: “If Andrew’s death did not warrant an SAER, then what would? Almost three years on I’m still struggling to get the full truth about Andrew’s death.”
Rab Wilson, who has been presented with the prestigious Saltire Award for his health campaigning and poetry, said: “Changes to the SAER system are not only supposed to ensure families are kept informed if mistakes are made, but NHS staff are also supposed to learn from mistakes.
“How can that happen when deaths like Andrew Slorance’s and Neil Alexander are not even being reported?”
The campaigner is also concerned that un-redacted investigation reports are not being made available to families, and that learning outcomes are not being published so the public can be reassured. While virtually all health boards reported increases, NHS Lothian reported 93 incidents last year. In 2016 there were 523.
Wilson said: “These figures stand out as they appear to buck the trend many times over. Health Secretary Michael Matheson must give the SAER scheme ‘teeth’ to ensure compliance and greater patient safety.”
NHS Ayrshire & Arran refused to discuss Neil Alexander’s death for confidentiality reasons. It said it took its “legislative responsibilities with regard to reporting to the Health and Safety Executive (HSE) and to other agencies such as the Crown Office and Procurator Fiscal Service very seriously”.
Healthcare Improvement Scotland said: “We recognise that there continues to be variations in how NHS boards apply this national framework.”
Health Secretary Michael Matheson said: “Healthcare Improvement Scotland is working closely with boards to address any variation in implementation of all elements of the framework.”
Dr Tracey Gillies, medical director, NHS Lothian, said: “We report level one events to HIS on a monthly basis and consider all adverse events for opportunities to improve care and our systems and processes.”
I was interested to read the above article published in the Sunday Post a few days ago. I worked in NHS Scotland as a doctor for over 25 years until I retired in 2020. As part of my job I participated in a number of Serious Adverse Event Reviews.
I recall the publication of this report which is now 10 years old:
I attended many training sessions on the Management of adverse events and was provided with updated reports on this ‘National framework’:
The year before I retired this edition was published:
I followed the guidance given in this report in a review of a serious adverse event that related to the death of a young patient [2019]. My experience was that the process was very helpful in looking at, considering and reflecting on all aspects potentially related to this tragic outcome. However, I was asked by a senior manager of the NHS Board that I worked for to change a number of aspects of the SAER report that I had helped compile. I refused to do so. I was then personally visited by senior management and was asked to use alternative language in the conclusions made in the report. I politely stood my ground, but to this day I do not know if the original version of the report was the one published by the NHS Board I worked for.
It is vital that we learn lessons from the past. Otherwise we risk repeating the same mistakes and avoidable harm and deaths will continue to occur. The following research, published just last year, reveals that this is a central concern for patients and families:
I was interested to read the assurance given in the Sunday Post [26 November 2023] by Dr Tracey Gillies: “We report level one events to HIS on a monthly basis and consider all adverse events for opportunities to improve care and our systems and processes.”
Dr Gillies was Medical Director in NHS Forth Valley during the time that I raised concerns about mis-diagnosis of dementia in elderly patients in our board area. The backdrop to this can be read here. Dr Gillies in her final letter to me, dated 16 March 2023, stated:
The “point” being made here seems to depart from collective learning that I have always understood as the essential basis of adverse event reviews.