Over 1000 ‘adverse events’ in women and infants’ care

Over 1000 ‘adverse events’ in women and infants’ care

Over 1000 investigations have been launched in Scotland over the last decade into adverse events affecting the medical care of women and babies.

Figures obtained by the Herald show that at least 1,032 Significant Adverse Event Reviews (SAERS) have been initiated by health boards since 2012 following “near misses” or cases of unexpected harm or death involving obstetrics, maternity services , gynecology or neonatal.

The actual figure will be higher as two health boards, Grampian and Orkney, have yet to respond to the freedom of information request, and several health boards have reported the totals per year to be “less than five” to protect confidentiality. of the patient.

In those cases, they have been counted as one, but the number could be up to four.

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Saers are internal board of health investigations that are conducted after events that could have resulted, or did result, in significant harm or death to a patient.

Major damage is generally classified as long-term disability or where medical intervention was required to save the patient’s life.

They are intended as learning exercises to establish what went wrong and whether it could have been prevented. Not all Saers are critical of patient care, but the goal is to improve safety.

Scotland’s largest health boards, NHS Greater Glasgow and Clyde and NHS Lothian, recorded the highest number of Saers, with 388 and 257 respectively.

NHS Lanarkshire was only able to provide data from April 2015, but this revealed a total of 194 Saers, of which 102 related to maternity or neonatal services, and 80 to obstetrics.

A fatal accident inquiry involving NHS Lanarkshire has already been ordered into the deaths of three babies, Leo Lamont and Ellie McCormick in 2019, and Mirabelle Bosch in 2021, because they had died in “circumstances that gave rise to serious public concern”.

The Crown Office said it wanted to “establish whether there is learning that could minimize the risk of future death in similar circumstances.”

The FAI is expected to take place in May next year.

Separate figures obtained under FOI also show that three negligence claims were brought against NHS Lanarkshire in relation to neonatal care over the last decade – two in 2015/16 and one in 2017/18.

Judith Park, director of acute services at NHS Lanarkshire, said: “Significant adverse event reports identify cases where there may be areas of treatment or care that did not meet the high standards we strive to offer each and every one of us. our patients.

“Saers gives us the opportunity to implement actions and learning that will ensure the failures are addressed.”

READ MORE: Neonatal deaths investigated by the health board at the FAI center

For Scotland as a whole, there is nothing to indicate that the number of Saers carried out on adverse events in obstetrics, maternity, gynecology or neonatology services has increased over the last decade.

In most regions, the numbers have fluctuated from year to year with no apparent upward or downward trend.

However, NHS Fife appears to have seen an increase since the start of the pandemic.

Between April 2020 and November this year, it started 31 Saers in total in contrast to fewer than five per year from 2012/13 to 2017/18.

In a statement, NHS Fife said this increase coincided with the implementation of new national guidance on the significant adverse event review process in January 2020, adding: “While the number of Saers performed has increased, the number of adverse events remained broadly constant over the stated period.”

NHS Tayside said it was unable to provide any data before January 1, 2020, but has since started at least three Saers in maternity and neonatal services.

The data also shows that NHS Greater Glasgow and Clyde has faced more malpractice claims over the past decade in relation to obstetrics, maternity, gynecology or neonatal services than any other board of health.

Figures obtained under FOI show that a total of 425 claims were filed between April 2012 and November this year, 204 of them in a single two-year period from 2013/14 to 2014/15.

As Scotland’s largest board of health, NHS GGC provides services to a core population of 1.2 million and specialist regional services to over half the country’s population.

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However, the number of negligence claims was almost three times that of the second largest board, NHS Lothian, which faced around 160 claims.

Not all claims for negligence will be accepted, but when it comes to boards of health, they are required to pay the first £25,000 of any settlement.

The remainder is funded by Scotland’s national Clinical Negligence and Other Risks Indemnity Scheme (CNORIS), a mandatory scheme in which all boards of health pay.

Excluding Grampian and Orkney, which have yet to respond to FOI requests, there have been at least 1026 malpractice claims on the NHS in Scotland since 2012 relating to obstetrics, maternity, gynecology or neonatology services.

In a statement, NHS GGC said: “Due to patient confidentiality, we are unable to comment on individual cases.

“In some cases, the time between incidents and claims being filed can be considerable, which can affect how the numbers are reported.

“At all times, NHSGGC staff strive to carry out their duties to the highest professional standards in accordance with national clinical guidelines.”

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