AN INVESTIGATION has revealed hundreds of previously secret NHS reports into serious incidents at Scottish hospitals – including 105 deaths.
The files include one case in which a person was “blown up” while being treated with oxygen therapy, patients dying or becoming ill when they were given the wrong doses of medication, and supplies of drugs or emergency treatment not being available.
The details have come to light after all NHS boards in Scotland were asked to produce reports into serious incidents that happened in its hospitals in the past year.
A total of 345 serious incidents were reported across Scotland’s boards
The probe showed a huge variation between NHS boards in the numbers of incidents reported and what sorts of investigations are conducted.
The reports demonstrate a big discrepancy between what boards consider to be serious – from a nurse injured while hanging Christmas decorations and a toaster used in an inappropriate area, to a baby who died during labour and a surgeon removing a healthy organ.
The largest health board, Greater Glasgow, reported relatively few incidents – 95, while Shetland has recorded 138 serious incidents this year.
The investigation, carried out by BBC Scotland, will be shown tonight in a programme called How Safe Is Your Hospital?
The programme also obtained new figures showing how much mistakes cost the NHS.
Over the past three years the Scottish NHS has paid out over £120 million in compensation and legal expenses. In two cases, NHS Lanarkshire paid out a total of over £6m.
Jim Martin, the Scottish Public Services Ombudsman, called for a national reporting system of serious incidents.
He said: “Now, if you’re in Lerwick or Larbert or Langholm, it really doesn’t matter, you know what the name of the process is. The important thing is what is the outcome of the process and can lessons be learned?
“I think … across Scotland we’re pretty confused about what we call things, what things mean and whether, for example, a critical incident review is a health and safety review, whether it’s a review of something that’s gone wrong surgically, or in a GP’s surgery, or in a dental surgery.”
The Scottish Government told the programme they had asked for an urgent review of incident reporting from Health Improvement Scotland (HIS), the body set up to support NHS Scotland and other healthcare providers deliver high-quality and safe services. Robbie Pearson, director of scrutiny and assurance at HIS, admitted they had no idea of the national picture.
He said: “At present we don’t know. That’s why we’re going out to all the NHS boards.”
As the number of complaints against the NHS amounts to 22 every day, the numbers upheld by the Ombudsman have also increased. Mr Martin said he was worried about the number of investigations carried out by the NHS into a patient’s care, where it has concluded it wasn’t at fault, but the Ombudsman has then found that to be wrong.
He added: “Last year we upheld something like 56 per cent of the complaints, which is a very worrying number, particularly given that the year before, the number was only 43 per cent. There seems to be an increase in the number of complaints not being resolved satisfactorily in health boards.
“I’m worried that if the trend continues, it will dilute the confidence of the population.”
A Scottish Government spokeswoman said a national framework for the management of adverse events was being put in place. She said: “Scotland is the first country in the world to implement a national patient safety programme across the whole healthcare system and has some of the safest hospitals in the world.
“We need to support a culture of openness, trust and quality improvement, so that we can make sure that lessons are learned from these events.”
‘I think they’ve taken her life away... she’s got nothing’
Elaine McMath Patrick’s mother, Margaret McMath, went into hospital with an infected toe on her right foot and came out having had half her left leg amputated, because it became infected too.
She believed that was as a direct result of poor care.
Ms McMath Patrick has not heard of a formal investigation into what went wrong being conducted, but she said she felt the NHS was not learning from its mistakes.
She is now her mother’s full-time carer, and she goes to look after her four or five times a day.
Speaking about her mother and how she was coping with her disability, Ms McMath Patrick said: “I think they’ve taken her life away. She never asked for anything. She didn’t ask for help. She did for everybody else.
“She had to get the leg off, the leg came off or she could die. She said to me, ‘Oh, we’ll see how it goes and maybe you could just help me commit suicide’… and she’s been asking me that ever since.
“She said I’ve got no life, she’s stuck in a chair. If she’s not stuck in a chair, she’s stuck in a hospital bed that we’ve got in our house for her, and that’s it.
“That’s what she’s got, absolutely nothing, nothing. I don’t let anyone go in wearing a sad face because I’ll put them back out the door. You go in, you’re cheery, you laugh, you laugh and joke.”
NHS Lanarkshire has refused to comment on the case.
‘Nobody has taken responsibility for baby’s death’
Jennifer Kennedy lost her baby, Elijah, when he was six months old. She believes it was mistakes made while she was in labour that eventually caused his death, and that the way the family have been treated by NHS Ayrshire and Arran afterwards made it all much worse.
Even after two investigations, she feels she still does not know what happened.
Jennifer says: “We’ve had no answer. There were different investigations and different people coming to different conclusions, and yet nobody high up has ever taken responsibility or wanted to sort it out.
“We’re still here all this time later, and we don’t know any more today than we did when Elijah died.”
Her partner, Allan Stirling, says: “My boy’s lost his life, my weans have lost their brother, I nearly lost Jennifer, and it’s like they’ve shrugged their shoulders and said these things happen.”
In a statement to the BBC, NHS Ayrshire and Arran said: “What happened to baby Elijah and his family is unbearably tragic, and they have our heartfelt condolences and apologies.
“The failings in care are detailed in the review document, which we have shared with the family.
“Following Elijah’s birth, the obstetrics department commissioned an internal review. However, our executive medical director felt a more detailed review, including root-cause analysis, was required.
“He also felt the original review did not answer some of the valid concerns and questions Elijah’s family had raised through the complaints process and in conversations with other staff.”