Secret Scottish NHS incident reports released
- 26 November 2012
- From the section Scotland
Hundreds of previously secret NHS reports into serious incidents, including 105 deaths, have been published by BBC Scotland.
More than 300 reports into the most serious incidents in Scotland's hospitals last year have been released.
The reports include a person being blown up while on oxygen therapy after lighting a cigarette.
They also detail deaths from fatal doses of medicine and missing equipment during a cardiac arrest.
Other reports show procedural problems in hospitals meaning patients died before they could be transferred and supplies of drugs or emergency equipment not being available.
The reports were released after a Freedom of Information request.
BBC Scotland has now published all the incident reports, which can be read by clicking through from the dropdown box below.
Former NHS staff have accused health boards of covering up mistakes rather than learning from them.
Scottish Public Services ombudsman Jim Martin said the bureaucracy in the NHS seemed to be more important than learning when things go wrong.
The Scottish government is conducting an urgent review of incident reporting and said there was no evidence that the system was putting patients at risk.
Research suggests about one in ten hospital admissions result in an "adverse event".
Health boards decide how they should be investigated and what lessons can be learned from any mistakes.
But the BBC Scotland Investigation, How Safe is Your Hospital? found a huge variation between NHS boards in the numbers of incidents reported and what sorts of investigations are conducted.
It was given access to 345 reports which demonstrate a big discrepancy surrounding what boards consider to be serious.
These range from a nurse injured while hanging up Christmas decorations and a toaster used in an inappropriate area to a baby that died during labour and a surgeon removing a healthy organ.
There is also a huge disparity in the way incidents are reported and investigated.
The biggest health board, Greater Glasgow, reported relatively few incidents (95) despite serving the largest population.
Meanwhile Shetland recorded 138 serious incidents in a year and Tayside's reports all listed almost identical learning points.
The public services ombudsman said it was "a confusing picture".
Mr Martin said: "I think if we had a simple national system it would be far easier to ask a simple question of the health service and get a clear statistical answer."
Dr Alastair Ross, a specialist in risk management at the King's Patient Safety and Service Quality Research Centre, said: "In the NHS we are very conscious that process and medical treatment has to be evidence-based.
"You wouldn't implement a drug or a treatment protocol without feeling that the evidence was very reliable and that it was going to make a real difference to patient safety and I don't think we should be doing that with the organisational side of things either."
International research suggests one in 10 hospital admissions can result in some kind of adverse event, whether that is a patient fall or an unexpected death, so learning from these mistakes can save lives.
Earlier this year, the health secretary ordered an investigation into NHS Ayrshire and Arran after the health board was severely criticised for withholding more than 50 reports on serious incidents at its hospitals and clinics.
Over a period of five years, NHS Ayrshire and Arran refused to release the critical incident and adverse event reports to staff.
A mental health nurse employed by the health board became concerned when he was involved in a critical incident, but never received a copy of the findings.
Rab Wilson was told he was not entitled to read the report, and would have to apply under FOI legislation.
Mr Wilson said he felt bullied by the NHS when he tried to raise his concerns.
Another nurse had to leave her job when she repeatedly asked for concerns about patient care to be addressed.
She said NHS Ayrshire and Arran tried to cover up mistakes rather than learn from them.
Having exposed serious weaknesses at NHS Ayrshire and Arran, Healthcare Improvement Scotland said it did not know the situation for other health boards in Scotland.
Robbie Pearson, from HIS, admitted they have 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. We're starting this month and we'll be around all the boards by the end of next year."