A BBC programme shown this week revealed details of over 300 serious incidents recorded in Scotland’s hospitals last year - 68 of those incidents from the Borders.
The ‘How Safe is Your Hospital’ investigation team used Freedom of Information requests to get the details but health boards’ interpretations of ‘serious incidents’ vary widely, some of the largest health trusts recording very few incidents, whereas the NHS Borders figures look higher than might be expected.
Evelyn Fleck, director of nursing and midwifery for NHS Borders, said “NHS Borders is committed to the delivery of safe, effective and person centred care for patients and members of the public. All incidents are required to be reported within 48 hours of the incident occurring. Once reported, incidents are reviewed by local managers and investigated locally or, if deemed necessary, escalated to a senior manager or clinician for investigation.
“Within NHS Borders, an investigation is undertaken for all incidents which are graded as having an extreme outcome and we consider incident reporting and investigation to be a very valuable tool for learning and improving safety for our patients and staff. NHS Borders is actively working with staff to increase reporting of all types and levels of incidents and near misses.”
As a result of the discrepancy between boards of reporting of serious incidents the Scottish Government is now carrying out an urgent review into incident reporting - the main purpose of the incident reports being so that lessons can be learnt .
Scottish Public Services ombudsman Jim Martin said bureaucracy in the NHS seemed to be more important than learning when things go wrong.
And when NHS Quality Improvement Scotland commissioned Dr Alastair Ross, a specialist in risk management, to look at the picture across Scotland he found disparities over what an adverse event actually is and how these events should be recorded. An example given is a nine page report from one hospital on floor coverings and how a national newspaper got its information, whereas NHS Borders produced a report that was less than a page into the death of a baby during childbirth.
One of the most serious incidents in the region last year was that of a still born baby being allocated a Community Health Index (CHI) number which meant that the baby was recorded as being alive on its first birthday and was sent a birthday card from Child Smile (oral health) Initiative. As a result the database was checked to make sure there were no other still born babies with live CHI numbers.
There were 13 obstetric and child health events recorded, six babies were still born and one mother had to undergo a hysterectomy after being readmitted after giving birth. She was given antibiotics but was readmitted a second time to have remaining placenta removed. She also had a perforation where a laparotomy was required and eventually needed a hysterectomy. The case was reviewed by the lead consultant.
On another occasion an expectant mother who was in labour was taken to the accident and emergency department instead of the labour ward. Medical staff were not made aware and the baby was delivered during transfer.
Eight of the serious incidents recorded by NHS Borders involved patient aggression, while other incidents recorded showed a delay of 3.5 hours in transferring a patient brought with a serious head injury to a neurosurgical ITU because there was no ambulance available to transfer them; a patient not given prescribed medication for five days because the ward had run out, resulting in seizures and sepsis but it was later discovered that the patient had a supply of the drug dispensed under the trade name; a Type One diabetic with high blood pressure recorded all weekend, but no action taken resulting in them being hyperglycaemic, hypotensive and septic and a review of guidance and protocol was undertaken, plus additional staff training and education; and three instances of patients suffering colonic perforation during or following a polypectomy.
Of the five record and data protection incidents two involved patients’ notes or charts being switched and another resulted in a body arriving at the mortuary with the wrong information.
On six occasions equipment failed. A patient had to be transferred to Edinburgh when they could not receive the necessary treatment in the Borders because of faulty equipment and on another occasion treatment had to be abandoned for a patient requiring urgent renal replacement, and a machine had to be borrowed from NHS Lothian.
A patient who went to the emergency department with abdominal pain was assessed and sent home, but was readmitted in the early hours in cardiac arrest. Another patient died within 24 hours of being examined and the resulting report looked at what could have been done differently concluding that the GP action was appropriate on the day, but with hindsight, there was a pattern of symptoms associated with the ultimate diagnosis; and another patient admitted with a heart attack later died after his transfer was delayed leading to an investigation being carried out.