The Management of Significant Adverse Events in NHS

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The Management of Significant Adverse Events in NHS Ayrshire & Arran – June 20128 The documentary evidence provided by NHS Ayrshire & Arran came from avariety of sources and included policy and procedural documents relating to thesignificant adverse event process, incident/event reports from the Datix riskmanagement system, sampled Significant Adverse Event Review Reports and relatedaction plans, process monitoring documents, governance group agendas and minutes.The documentary evidence included a recent NHS Ayrshire & Arran Internal AuditReport from PricewaterhouseCoopers (PwC) published in November 2011. Collationand analysis of the material was undertaken by the staff of Healthcare ImprovementScotland.9 A visit to NHS Ayrshire & Arran was conducted on 29 and 30 March 2012 and aseries of follow-up interviews were held by teleconference in April and May 2012. Theinterviews that were conducted included a wide range of staff and frontline operationalstaff, support staff, directors and the Chief Executive. In addition, there were interviewswith the former chair of the Clinical Governance Committee and Mr Wilson.10 Alongside the overall review of the system for the management of significantadverse events, the Review Group examined, in depth, seven significant adverse events,covering a mix of specialties. The analysis of the sampled cases, the policy and relatedprocedures and also a review of other key reference documents, allowed the ReviewGroup to shape a number of additional requests for information and also thedevelopment of a series of questions and prompts for the visit to NHS Ayrshire & Arranon 29 and 30 March 2012. This allowed additional focused questioning of the process tothe staff either involved in a particular incident or its review.11 The Review Group received considerable support and assistance throughout thereview from the staff in NHS Ayrshire & Arran, and is grateful for their time andcommitment. The Review Group is particularly appreciative of the openness shown bythose they met and interviewed.12
The Management of Significant Adverse Events in NHS Ayrshire & Arran – June 20122 NHS AYRSHIRE & ARRAN’S DESCRIPTION OFARRANGEMENTS12 NHS Ayrshire & Arran has demonstrated an ambition to develop an approachthat reflects the key principles of a safer system of care. Over the past several years, ithas been apparent that there has been considerable effort in creating a newinfrastructure and policies to support the identification, investigation, management andlearning from significant adverse events in NHS Ayrshire & Arran. A strong feature of itsapproach is the involvement of patients and families in the open sharing of informationarising from significant adverse events.13 NHS Ayrshire & Arran employs 10,000 staff and has a revenue budget of around£590m for 2012/13. NHS Ayrshire & Arran’s organisational structure is set out inFigure 1. The Healthcare Directorates are described in this diagram. They are led by aDirector accountable to the Chief Executive and are supported by an Associate MedicalDirector and an Associate Nurse Director.Figure 1: Organisational structure14 The Chief Executive of NHS Ayrshire & Arran presented to the Review Group on29 March 2012 the history of the development of the Adverse Event Policy andSupporting Procedures. Figure 2 shows the timeline for the development of policychanges. The current policy (Version 4) was the subject of extensive consultation overthe course of 2010.13
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The Management of Significant Adverse Events in NHS

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