The Management of Significant Adverse Events in NHS

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The Management of Significant Adverse Events in NHS Ayrshire & Arran – June 2012Review Group membershipRobbie Pearson (Chair)Dr Gordon BirnieProfessor Kevin RooneyDr Mags McGuireRobin CreelmanDr Lorna RamsayDr Lesley Anne SmithMark AggletonDirector of Scrutiny & Assurance,Healthcare Improvement ScotlandMedical Director, Operating Division,NHS FifeUniversity of the West of Scotland, andConsultant in Intensive Care, NHS GreaterGlasgow and ClydeNurse Director, NHS TaysidePublic Partner and Non-ExecutiveDirector, NHS HighlandClinical e-Health Lead and DivisionalCaldicott Guardian, NHS National ServicesScotlandHead of Quality, NHS HighlandControls Assurance Manager,Healthcare Improvement ScotlandProject management support will be provided by the Directorate of Scrutiny &Assurance team at Healthcare Improvement Scotland.38
The Management of Significant Adverse Events in NHS Ayrshire & Arran – June 2012APPENDIX 2: EVENTS LEADING TO THE REVIEWFrom 2006 onwards, Mr Wilson made a number of requests to see a Critical IncidentReview Report and action plan. This was followed up by requests for furtherinformation regarding Critical Incident Review Reports held by NHS Ayrshire & Arran,culminating in a request in February 2011 for all Critical Incident Review Reports andSignificant Adverse Event Review Reports (and the action plans derived from these)from January 2005.Mr Wilson was unhappy with the response from NHS Ayrshire & Arran and appealed tothe Scottish Information Commissioner. The Scottish Information Commissioner set outhis conclusions in Decision Notice 036/2012.NHS Ayrshire & Arran, in direct response to the concerns expressed regarding themanagement of significant adverse events, also commissioned PricewaterhouseCoopers(PwC) to carry out an investigation. The results of that investigation were reported tothe Clinical Governance Committee of NHS Ayrshire & Arran in December 2011,followed by an action plan presented to the Clinical Governance Committee in February2012.The PwC report made 13 recommendations for improvement but noted that “since 2006,particularly since 2009, there have been substantial improvements, with strong leadershipsupport in respect of significant adverse event reviews, and with a clear strategy to makethis process effective and consistent across all services within NHS Ayrshire & Arran”. Thecover report to the Clinical Governance Committee acknowledged that“recommendations were also made in order to support ongoing improvements particularlyaround report sharing and lessons learned, it was highlighted that these are not criticalrisks to the organisation, and do not have a significant impact on patient safety”.NHS Ayrshire & Arran issued press statements in response to the conclusions of theScottish Information Commissioner on 22 February 2012 and stated that:“In his request, Mr Wilson asked for copies of Critical Incident Reviews (CIRs) andSignificant Adverse Event Reviews (SAERs) which had been completed since January 2005,along with action plans relating to the reports.We acknowledge that the Commissioner’s criticism of NHS Ayrshire & Arran’s recordsmanagement system prior to 2009 is justified, and apologise that Mr Wilson has had to goto significant lengths to receive the information he requested.I would like to reassure the public that there has never been any intention to deliberatelywithhold information from Mr Wilson to which we thought he should have been entitled.Where we applied the Act to exempt information from disclosure, again we did so in goodfaith.We identified failings in our system for conducting and recording CIRs back in 2009. As aresult we took steps to improve the way in which we as an organisation conduct incidentinvestigations. A vital part of this process is how learning is applied to improve patient39
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The Management of Significant Adverse Events in NHS

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