Grieving dad says NHS not learning from mistakes
Fraser Morton's baby son, Lucas, was one of six "unnecessary" baby deaths at Crosshouse Hospital in Kilmarnock nearly a decade ago.
The scandal sparked a shake-up of how safety incidents are reviewed but concerns have been raised about the quality and effectiveness of these investigations.
More than 800 safety incidents were reported in the NHS last year - a 41% increase from 2020 - and health watchdogs are now revamping the reporting system to improve scrutiny.
The rise in reported Significant Adverse Event Reviews (SAERs), which include avoidable deaths, comes as the NHS has faced unprecedented pressure since the Covid pandemic.
Mr Morton said he'd seen little of the promised changes, such as the appointment of an independent patient safety commissioner, since the death of his son in 2015.
He said: "In 2016, the Organisation for Economic Cooperation and Development (OECD) said Scotland's healthcare system was marking their own homework when it came to reviews and investigations and we've not made any progress since then.
"Deny, deflect, delay - that's the go-to tactic."
Mr Morton's son Lucas died after a series of failings, including not properly monitoring his heartbeat during childbirth, but the death was not investigated as an SAER.
Only after pressure from the family and a BBC investigation was a fuller review launched with NHS Ayrshire and Arran then admitting Lucas's death was "unnecessary" and issuing the family an "unreserved apology".
Mr Morton added: "It is the lack of independent scrutiny that concerns me.
"Mistakes will always happen, but the NHS is the only high- risk, high-consequence organisation or sector that doesn't have an external regulator, a truly independent regulator you [can] compare to say the rail, airline or nuclear industry."
NHS Ayrshire & Arran declined to comment.
Figures released under freedom of information laws to BBC Scotland show that in 2020/21, a total of 567 SAERs for the most serious of incidents - events which may have contributed to or resulted in permanent harm - were carried out by Scotland's health boards.
By 2022/23 this had risen to 772 and last year the total was 803.
NHS Greater Glasgow and Clyde accounted for 783 of the 2,759 reviews commissioned in this period, followed by NHS Lothian (341) and then NHS Lanarkshire (310).
Alison Fisher has spent years trying to get answer on why the birth of her daughter Fiadh at Glasgow's Princess Royal Hospital did not go to plan.
Details about what went wrong, which include wires missing from a foetal heart monitor, have slowly emerged as she has pushed for more answers.
"I found it so traumatic. It's my first child, it's supposed to be a really special moment, and I just want to understand what happened," she said.
A complaint to NHS Greater Glasgow and Clyde after the birth of Fiadh in 2021 resulted in an apology and the board said it had taken action to improve care at the hospital.
But Alison, of Kirkintilloch in East Dunbartonshire, then took her case to the Scottish Public Services Ombudsman (SPSO), which is the final stage for complaints about public organisations.
The SPSO took two years to investigate but in 2023 upheld Alison's complaint that the board had failed to provide reasonable care and treatment during her labour.
It also ruled she and Fiadh had not been put at risk.
NHS Greater Glasgow and Clyde had not classed the incident as an adverse event and the SPSO concluded it should have been.
The board initially told the SPSO that a Datix report, the NHS system for recording incidents, had been created for the case but later admitted this was incorrect, and the ombudsman said it should have been produced at the time.
Alison added: "You kind of sit with that and you think, okay, maybe I'm being hard on them. Maybe I'm bashing them, maybe I'm being paranoid, but after two and a half years, you learn you're not being paranoid. You need to trust your instincts."
After her SPSO compliant was upheld, Alison asked NHS Greater Glasgow and Clyde to carry out a SAER but the board refused saying the case did not meet the criteria and had already been investigated.
Dr Claire Harrow, Deputy Medical Director for Acute Services for the health board, said: "We have apologised to this patient for her experience. We know that some aspects of her care did not meet the standards patients should expect, and we are sorry for that.
"We fully accepted the recommendations made in this 2023 SPSO report, and these have been met in full."
Among the long-standing issues with the SAER system is how health boards categorise incidents and a lack of clarity of what learning from the reports is being shared.
BBC Scotland has spoken to a number of families who have been involved in a SAER who say they felt that they were not being told the full story and the health board was trying to minimise the seriousness of the incident.
An independent review into serious failings with mental health services in Tayside found that the SAER was "perceived by families as a tick-box exercise" and did not get to the root cause of the issues.
In 2019, the Scottish government told HIS to sort out the inconsistencies in reporting approaches taken and ordered health boards to start reporting how many of the most serious SAERs they are commissioning.
HIS has been working on a revamp of the SAER notification system and guidelines which will "enable effective learning at national level" about the harms taking place and achieve greater consistency across the boards in terms of defining which incidents should be investigated.
The new guidelines will expect boards to improve the way patients and their families are involved in reviews and Moira Manson, who leads the HIS adverse events programme, said the new approach will improve patient safety.
She said: "There is progress. Progress isn't at the pace that we would expect but we've had a pandemic in the middle of this.
"The boards are learning from each other's mistakes and what we are seeing is a real willingness from our NHS boards to work together collaboratively to improve the system in terms of adverse events."
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