Maternity hospitals record 25,000 adverse incidents

Scotland's maternity hospitals have recorded more than 25,000 adverse incidents since 2011, BBC Scotland has discovered.

The most serious cases included the deaths of 26 newborns and 79 stillbirths. Three mothers also died.

Staff shortages, medicines given in error and treatment delays were also among the incidents logged.

The Scottish government pointed out that in 2015 the country had recorded its lowest level of stillbirths.

Health Secretary Shona Robison also said that there were fewer neonatal deaths and fewer maternal deaths.

The minister's comments came following a BBC Scotland Freedom of Information (FOI) request into the number of "adverse events" taking place in maternity units.

Across Scotland from the beginning of 2011 until the end of 2015 there were more than 285,000 births, including 1,247 stillbirths.

Health board detailed minor incidents including slips, trips, bumps and falls, but also more serious events including:

• A pregnant woman involved in a "radiation incident";

• A newborn baby died due to a spinal cord injury following a forceps delivery;

• Five reports of staff behaving inappropriately or in a hostile manner;

• Three occasions in 2013 at one hospital when medical equipment "failed" during an operation;

• More than a dozen medication-related events at one health board including instances where the wrong medication was given, the wrong dosage was administered, and where the medication wasn't administered at all.

In reality the total figure may be far higher than 25,000, because some health boards - including Greater Glasgow and Clyde - provided only the most serious events rather than all adverse events.

The figures did reveal almost 500 incidents in relation to staff shortages, more than 440 referring to medicine given in error, and more than 100 delays in treatment.

The FOIs also showed evidence of a series of staffing problems at health boards in Fife, Grampian, Highland and Lanarkshire.

It has raised questions over how many of these adverse events could have been avoided.

On Monday, the Scottish government announced an independent investigation into baby deaths at a Kilmarnock hospital.

Ms Robison said Healthcare Improvement Scotland would review care at Crosshouse after BBC Scotland revealed six so-called "unnecessary" deaths of babies at the hospital since 2008.

Fraser Morton said NHS Ayrshire and Arran health board had refused to carry out a review following the death of his son Lucas in Crosshouse Hospital last year.

June and Fraser Morton believe hospital staff were overworked in the lead-up to their son Lucas being born

He believed a shortage of staff and a lack of training contributed to the death of his son.

Gillian Smith, the director of the Royal College of Midwives (RCM), said there was a definite correlation between staff shortages and adverse events.

With new figures showing that more than 40% of Scotland's midwives were in their 50s and 60s, she warned that the country was facing a "demographic timebomb".

Ultimately accountable

She added: "There are always going to be adverse events of some kind... mothers and babies will still die for reasons we don't know and couldn't avoid.

"However, what we want is to look at all the avoidable incidents and take the learning we can from that.

"Learning from avoidable incidents in the only way we will get better."

Ms Robison told the BBC's Good Morning Scotland programme that she had full confidence in Healthcare Improvements Scotland to carry out the national review of maternity services, which will report in a few weeks' time.

She added: "Its remit will be to look into the questions being asked by families to make sure that the processes and procedures that should have been followed within Ayrshire and Arran were followed and to report to me after looking into all of those issues."

She acknowledged that she was ultimately accountable if future failures in the system were not addressed.

She said: "Accountability lies both with the board and ultimately the chief executive of that board and eventually, yes, with me. Which is why that we need to make sure that all of these adverse events are subject to review, that lessons are learned. "

In figures: Stillbirths in Scotland

• Scotland has one of the highest rates of stillbirth in the developing world, with one in 200 pregnancies ending in stillbirth

• There were 158 stillbirths in Scotland 2015 - a figure which has almost halved since 1990

• A total of 55,098 babies were born alive in 2015

A project by the Royal College of Gynaecologists (RCOG) aims to halve the number of "avoidable" stillbirths in the UK by 2020.

Its Each Baby Counts programme found 1,000 incidents of avoidable harm at birth in its first year of monitoring - with about 100 of them in Scotland.

Prof Alan Cameron, the principal investigator on the UK wide project, said: "Some of these events don't cause any harm but they are recordable as adverse events. But some can cause harm and what is key is that the service sits up to recognise that and do something about it.

"Some of the events we have looked at are staggering. Some of the reports we have read beggar belief.

"Labour is the most hazardous journey a baby makes. If something goes wrong health service staff have to act quickly. That can be alarming. This is such an acute and unpredictable specialty."

He said BBC Scotland's findings showed that health boards had different classifications for serious adverse events, and he called for consistency.

He added: "It is a concern that some areas are not doing as well as others in terms of outcomes from labour.

"I would certainly hope another Morecambe Bay would not happen again and that is why we need to put mechanisms in place to prevent it happening in future."

Analysis - By Marc Ellison, BBC Scotland data journalist

Filing Freedom of Information (FOI) requests to Scottish authorities is nearly always an exercise in frustration. If they are not late they are incomplete, if they don't give you what you ask for they don't give it to you at all.

My request to the country's health boards for adverse event information hit more snags than usual. The responses issued gave a patchwork quilt of data - a frustratingly blinkered view of the actual figures. The ensuing inconsistent mishmash of data ultimately boiled down to how boards had interpreted what I meant by "adverse event".

Some only returned data on "serious" adverse events - those incidents that resulted in actual loss of life. Others returned events classified as "minor", "major" or "significant" - they included anything from falls and staff shortages, to a pregnant woman involved in a "radiation incident".

The waters were muddied further by some overly enthusiastic redaction of internal adverse events reports, partial returns with some data missing, and some responses citing only annual totals without giving us an idea of the type of adverse event.

But even as a partial snapshot these figures are rather alarming. These varying returns mean we don't know exactly how many adverse events occurred, determined how they have been dealt with (to ensure that they could be avoided in future), and nor can we say with 100% certainty whether the number of adverse events in our hospitals is falling.