NHS Scotland to be more 'open' about mistakes

BBC Scotland published hundreds of previously secret reports into serious incidents from across the NHS in Scotland

The NHS in Scotland is to adopt new rules on how it handles investigations when things go wrong.

It follows a scandal at NHS Ayrshire and Arran in which the health board withheld more than 40 reports about serious incidents involving patients.

The new rules aim to ensure that anyone affected is treated in the same way and lessons are learned across the NHS.

David Farquharson, of NHS Lothian, said it showed a new commitment to "openness and learning from errors".

The national approach is intended to cover all care provided throughout NHS in Scotland.

Freedom of information

Last year, the health secretary ordered an investigation into NHS Ayrshire and Arran after the health board was severely criticised for withholding reports on serious incidents at its hospitals and clinics.

Over a period of five years, it refused to release the critical incident and adverse event reports to staff.

BBC Scotland then published hundreds of previously secret reports into serious incidents from across the NHS in Scotland, including 105 deaths.

More than 300 reports, which had been obtained after a freedom of information request, were released, including one about a person being blown up while on oxygen therapy after lighting a cigarette.

They also detailed deaths from fatal doses of medicine and missing equipment during a cardiac arrest.

Other reports showed procedural problems in hospitals meaning patients died before they could be transferred and supplies of drugs or emergency equipment not being available.

Former NHS staff accused health boards of covering up mistakes rather than learning from them.

Scottish Public Services ombudsman Jim Martin said the bureaucracy in the NHS seemed to be more important than learning when things go wrong.

The latest report - Learning from adverse events through reporting and review: A national framework for NHSScotland - outlines consistent definitions and a standardised approach across the country.

It says that NHS Scotland should maximise the opportunities for NHS boards to share and actively learn from each other in order to put improvements into practice.

The national approach seeks to ensure that no matter where an adverse event occurs in NHS Scotland:

• the affected person receives the same high quality response

• any staff involved are treated in a consistent manner

• the event is reviewed in a similar way, and

• learning is shared and implemented across the organisation and NHS Scotland to improve the quality of services.

David Farquharson, medical director of NHS Lothian and co-chair of the Healthcare Improvement Scotland's adverse events programme board, said it showed "a new commitment and approach to patient safety within the NHS in Scotland".

He said: "A national commitment to openness and transparency and learning from errors will ensure that NHS Scotland becomes an even safer environment for patients.

"The challenge now will be to embed the practices and principles within every NHS board."