Latest news with #SAER
STV News
3 days ago
- Health
- STV News
'We trusted them with our boy - we'll never forget how he suffered'
The mother of a boy left with lifelong injuries after a series of morphine underdoses at Scotland's largest children's hospital warns there will be another incident unless urgent changes are made. Ellie McAdam's son Theo was one of seven children given a tenth of the pain relief they should have had after undergoing the surgery at the Royal Hospital for Children in Glasgow last summer. The underdoses affected seven operations over six days within a single theatre between June 13 and 24 last year but were not discovered until nearly a month later, on July 6. A review by NHS Greater Glasgow and Clyde (NHSGCC) following the incidents found that overworked and fatigued staff at the Royal Hospital for Children in Glasgow missed vital checks. But Theo's mother, Ellie McAdam, from Peterhead, fears another child could be harmed unless action follows. 'I have no doubt that there will be a next one. I have no doubt it will – unless serious changes are made. 'Every birthday for Theo is so much more than a birthday because we're just glad he's still here.' STV News Theo was four weeks old when he needed the first of two open-heart surgeries. After undergoing his second open heart surgery, a critical mistake meant he received just a tenth of the morphine he needed – 1.5mg instead of 20mg. Ellie said her son ripped all his lines out in pain and collapsed his own lung. 'That's not repairing itself at all. We don't know the impact it'll have – it's seeing how it affects him long-term. 'He was genuinely traumatised. He was a completely different boy. 'Because he was so little, he got over it – which is amazing, but we'll never forget it. I can speak on behalf of many other families; they won't either. 'It's had a lasting impact. We're still dealing with the aftermath. It has caused a lot of pain and suffering.' An investigation has now been undertaken, which revealed a catalogue of failures. STV News The review found that 10mg of morphine had been ordered by theatre staff, but that the strength delivered was only 1mg. Staff assumed the order was correct, and the wrong amount was then used. A new stock system was also blamed, with the review citing the font size and colour made it difficult to read the amount of milligrams. A review found the seven children, including Charlotte, were administered 1mg/ml of morphine – when they should've received 10mg/ml. The report also found that the underdose went unnoticed for nearly a month due to staff going on 'assumption' rather than doing two-person checks as the procedure requires. It concluded that human and systematic factors played a significant role. The Significant Adverse Event Review (SAER) by NHSGGC also found that staff were overworked and overtired during shifts. The review recommendations included additional staff training and an improved stock management system to ensure 'any incident of this nature is prevented from happening again'. NHS Greater Glasgow and Clyde have again apologised to the families impacted and say they've begun the process of implementing the recommendations. STV News But Theo's mother, Ellie, said the review does little to address the reality of what happened. 'The review felt like a half-hearted acknowledgement of them not following their own policies. It doesn't really take any accountability for what happened. It diminishes the lived experience of the families who went through it. 'It seems almost dismissive of the human error. They called it 'local rationale' for the staff making these assumptions – you can fluff it up with a name all you want, but it's complacency. 'The tone is 'these things happen', but that's not good enough. These people are handing their babies, their whole world, to you. 'The review found that staff were tired and overworked – then hire more staff, stop paying your big bosses £200,000 and put more boots on the ground. 'If it's leading to these kinds of things, you need to do better. Take a look at yourselves and think, 'this isn't working, we need to change it.'' Ellie McAdam She added: 'I'm not on a witch hunt for someone's job, but several people didn't do theirs. You've not done the checks you're meant to do. I'd be held accountable if I didn't do my job, so what's going to change?' It's now been more than a year since Theo's surgery, and he is continuing to recover. But its been very hard on Ellie. She believed her son was in the safest place – and and says she still feels the lasting emotional impact of the ordeal. 'There's anxiety knowing they've done this, and even though they're saying 'maybe it's our fault,' what can you do? 'To then have to put him back in that situation, you think 'are they going to do their checks, all the points that need to be done to ensure he's safe?' I don't know. But we have no choice either way. 'I know what's happened and that we are going back. I can't imagine how we will cope when that time does come.' NHSGCC apologised and said families have been invited to meet with members of the review team to discuss their concerns. 'We know the care these patients received fell below the standard expected, and we are sorry,' a spokesperson for the health board said. 'Both human and systems factors played a role in this incident, and we are committed to ensuring that lessons are learned from this extensive review, which was carried out with the involvement of pharmacy, nursing, and medical staff, as well as an individual panel member providing expert opinion.' The health board said it began implementing the report's five recommendations as soon as the error was identified. 'It includes recommendations around staff training, the physical environment and stock management system, which are designed to ensure any incident of this nature is prevented from happening again,' the board said. Get all the latest news from around the country Follow STV News Scan the QR code on your mobile device for all the latest news from around the country
STV News
6 days ago
- Health
- STV News
'We put our baby in their hands - she ended up in unnecessary pain'
The parents of a baby who was given a fraction of the morphine she should have after undergoing open-heart surgery say they are still seeking accountability. Baby Charlotte Gilchrist is one of seven children who were given a tenth of the pain relief they should have been after undergoing the surgery last summer. The underdoses affected seven operations over six days within a single theatre between June 13 and 24 last year but were not discovered until nearly a month later, on July 6. A review by NHS Greater Glasgow and Clyde (NHSGCC) following the incidents found that overworked and fatigued staff at the Royal Hospital for Children in Glasgow missed vital checks. Charlotte was just 11 weeks old when her parents were told she would need open-heart surgery. Charlotte's mum Coral told STV News: 'I kept saying there is something not right (with Charlotte) – I didn't want to be right.' STV News 'You automatically think the worst', Charlotte's father, Craig, said. Everything froze for the couple until after a two-hour-long surgery when they were supposed to be in the clear. Craig still thinks of the videos he took of Charlotte post-surgery. 'Now, when we look back at videos, I feel dead guilty because, you can see, she's in pain', he explained. The couple later discovered that Charlotte was given an underdose of crucial pain killers following the procedure. STV News A review found the seven children, including Charlotte, were administered 1mg/ml of morphine – when they should've received 10mg/ml. The report also found that the underdose went unnoticed for a month due to staff going on 'assumption' rather than doing 'two-person checks' as procedure requires. NHSGCC has apologised to the families and said it has begun implementing the recommendations in the report. But Craig and Coral say that they are still 'heartbroken' and don't think the recommendations are enough. Coral broke down in tears as she told STV News: 'We handed over our world to somebody else's arms and they didn't look after her the way they should have.' The Significant Adverse Event Review (SAER) by NHSGGC also found staff were overworked and overtired during shifts. The review recommendations included staff training and stock management to ensure 'any incident of this nature is prevented from happening again'. But families affected say that isn't enough. STV News Coral added: 'There were lots of minor issues that were just careless, and there were a lot of them. 'It was bad enough she had to go through heart surgery, and even though we're thankful, she was still in unnecessary pain. 'We deserve to find out what has actually happened with that. Are there disciplinary hearings going ahead? 'You can give all the training you want, but unless it's implemented in practice, it's not going to make a difference. 'Over a year after her surgery, and we're still having to relive that with every email and every conversation. 'When you properly sit and think about it, it breaks your heart'. STV News spoke to two other families affected by the incident, who are also disappointed and feel like the review raises more questions than it answers. STV News Ellie McAdam, mum to three-year-old Theo, said she felt the report was a 'half-hearted acknowledgement of not following policy, but it falls short of real accountability'. Two-year-old Kai Campbell's mother, Shelby, shared the sentiments, adding that she was 'shocked' as the report 'was just full of so many excuses.' While Charlotte won't need any more heart surgery, Coral still wants to ensure no parent or child goes through the same ordeal. Carol said: 'My heart goes out to the families who have gone through this and do need future surgeries. 'I know how anxious it's made me, and I can't imagine how anxious they are knowing that some point in the future they will need more surgery.' NHSGCC apologised and said families have been invited to meet with members of the review team to discuss their concerns. 'We know the care these patients received fell below the standard expected, and we are sorry,' a spokesperson for the health board said. 'Both human and systems factors played a role in this incident, and we are committed to ensuring that lessons are learned from this extensive review, which was carried out with the involvement of pharmacy, nursing, and medical staff, as well as an individual panel member providing expert opinion.' The health board said it began implementing the report's five recommendations as soon as the error was identified. 'It includes recommendations around staff training, the physical environment and stock management system, which are designed to ensure any incident of this nature is prevented from happening again,' the board said. Get all the latest news from around the country Follow STV News Scan the QR code on your mobile device for all the latest news from around the country
Sunday Post
11-05-2025
- Health
- Sunday Post
Health boards urged to end preventable death review ‘culture of secrecy'
Get a weekly round-up of stories from The Sunday Post: Thank you for signing up to our Sunday Post newsletter. Something went wrong - please try again later. Sign Up Government ministers face a mounting backlash over secrecy as almost 1,000 preventable death and accident reviews a year in Scottish hospitals go unpublished, we can reveal. Not a single health board is making redacted Significant Adverse Event Reviews (SAER) available to the public, despite guidance telling them to do so. The Sunday Post was praised in parliament last week for revealing how 500 babies died and dozens of mothers lost their lives in maternity units over the past five years without officials being required to explain why. MSPs expressed frustration that Scottish Government promises of greater transparency – made after two inquiries into maternity care a decade a go – have been ignored. Now Scotland's Information Commissioner is joining calls for an end to secrecy to make our NHS safer and prevent a recurrence of scandals like Dr Harold Shipman, Lucy Letby and our own NHS Tayside scandal involving rogue surgeon 'Sam' Eljamel. Official inquiries at NHS Ayrshire & Arran over six baby deaths, and at NHS Highland over five avoidable deaths, led to the Information Commissioner ruling SAERs should be redacted and made available on health board websites. A decade on, health officials refuse to make information available, hiding behind data laws. Tory MSP Stephen Kerr is demanding answers from Public Health Minister Jenni Minto. He said: 'It's a matter of public interest, moral duty and democratic accountability that these reports are published, redacted where necessary, so the public can be assured that the NHS is learning from its most serious failures. 'The failure of ministers to act on this is no longer a neutral stance – it is complicity in the ongoing denial of accountability.' Kerr lambasted Minto over her lacklustre response, demanding assurances that the current system is not being used to 'obscure rather than illuminate critical failures in patient safety'. He said: 'These are not statistics, these are human tragedies – avoidable ones.' Scottish Labour deputy leader Dame Jackie Baillie said: 'Learning from mistakes is the best way to improve patient safety, so this lack of transparency is deeply worrying.' And Lib Dem leader Alex Cole-Hamilton said: 'This looks like it could be a major scandal. We have seen from previous scandals that institutions can be reluctant to draw back the curtain and allow sunlight in. If they are unwilling to do this, ministers will have to turn up the pressure.' Information Commissioner David Hamilton is urging more transparency where possible. He said: 'Sharing of learning from significant adverse events that arise in our hospitals is a crucial part of preventing a reoccurrence. If learning can be shared publicly in a way that does not breach data protection or patient confidentiality it may be good practice to do so, to support scrutiny and accountability and build public trust.' The commissioner said that while not every case may be suitable for publication, health agencies should consider change. He added: 'We would expect to see the learning published where possible. 'Where information isn't made public, people still have rights under Freedom of Information (FoI) law to ask for it, followed by a right to appeal to my office if they feel it has been unjustly withheld.' © Sandy McCook / DC Thomson Health boards across Scotland refuse to issue figures on how many avoidable deaths or how many SAER reports there have been without FoI applications, which take months. Louise Slorance, the widow of government official Andrew, 49, who died five years ago after contracting Covid-19 and the fungal infection aspergillus while receiving cancer treatment at the Queen Elizabeth Hospital in Glasgow, said: 'The continued deliberate culture of secrecy over patient deaths has become Scotland's shame. 'I've had years of fighting to get to the truth over Andrew's death despite promises of openness from former first minister Nicola Sturgeon, so what chance have other families got?' The Scottish Government said: 'We expect all boards to follow guidance to ensure robust and timely reviews are undertaken into such tragic events, to allow lessons to be learned at the earliest possible opportunity.'
Sunday Post
04-05-2025
- Health
- Sunday Post
Veil of silence over mother and baby deaths in Scottish hospitals
Get a weekly round-up of stories from The Sunday Post: Thank you for signing up to our Sunday Post newsletter. Something went wrong - please try again later. Sign Up Around 500 babies have died in Scottish hospitals since 2019, but health authorities have managed to avoid any public scrutiny, we can reveal. Our special investigation into maternity care standards has found dozens of mothers also lost their lives over the past five years, but health officials face no sanctions for refusing to say why. Promises for 'openness and transparency' were given by Healthcare Improvement Scotland (HIS) following the deaths of six babies at NHS Ayrshire and Arran's Crosshouse Hospital almost a decade ago, and again after 'sub-optimal care' was linked to five baby deaths at NHS Highland's Caithness General Hospital around the same time. HIS told health boards to share and learn from tragedies by publishing Significant Adverse Event Reviews (SAER), involving families and staff, in a bid to prevent further deaths and injuries. But despite this, both NHS Ayrshire and Arran and NHS Highland are among health boards still refusing to publish SAER reports. Now bereaved parents say Scottish health boards have become even more evasive, leaving families battling for the truth. College lecturer Fraser Morton, 47, whose son Lucas was one of six babies whose deaths were found to have been avoidable in the Ayrshire & Arran scandal, said: 'All these years on, the betrayals continue while more lives are lost. Despite all the promises and millions spent on supposedly making the system more transparent, it's now even harder for bereaved families to get to the truth.' While NHS England is currently examining the deaths of over 2,500 babies, Scottish health officials refuse to publish vital reports to scrutinise maternity ward safety. © Andrew Cawley Contacted by The Sunday Post last week, NHS Ayrshire & Arran insisted it was government quango HIS which ordered them to stop publishing SAERs. Medical director Dr Crawford McGuffie said HIS 'advised' that the health board stop published redacted SAERs as 'these reports do not encourage shared learning and risk breaching patient and family confidentiality'. He said: 'As a result, all SAER reports were removed from our website.' It would not even reveal how many maternity related deaths occurred in the past five years, only saying 26 SAERs were instigated. Scotland suffers 100 baby deaths every year, with dozens of mothers also losing their lives, while England has a thousand babies dying annually. But while England has the coroner's system to identify 'red flags' over standards, campaigners warn Scotland's secrecy and failure to publish reports prevents scrutiny. Morton said: 'If a hundred lives were being lost every year in an industrial setting there would be a public outcry. But because this is happening in hospitals, health officials are getting away with secrecy. 'Quite apart from the broken promises on transparency made to parents like us, the Harold Shipman inquiry highlighted the importance of openness to prevent recurrence. That's why publishing SAERs is vital for public safety. 'Our health boards learned nothing from the tragedies of the past except how to make it even more difficult for families to find out the truth when things go wrong. Politicians cannot let this continue. 'Nothing can be more distressing than losing a child. Not being told why exacerbates the pain. 'With no proactive independent scrutiny, our health boards continue marking their own homework in while hundreds of lives are being lost with no explanation or accountability.' HIS said: 'The decision to share a SAER report publicly would be for individual NHS boards to decide. NHS boards currently notify us when commissioning such a review, but do not share the full report with us.' Former nurse Rab Wilson, whose disclosures led to the Ayrshire & Arran baby deaths inquiry, said: 'When mistakes cost lives, there is a duty of candour to inform the public. 'Without public access to SAERs, how can anyone even begin to spot red flags or make the vital links which could save lives.' © Jane Barlow/PA Wire Our probe showed NHS Highland, where five baby deaths were linked to 'sub-optimal care' at Caithness General, refused to give the number of deaths of infants and mothers, admitting they don't publish SAERs. NHS Lothian recorded 300 'maternity related deaths' between 2019 and 2024 with Edinburgh Royal Infirmary recording 253, and St John's in Livingston 47, and the deaths of less than five mothers every year apart from 2022. It refused to publish further details claiming data rules. NHS Lanarkshire had 224 babies dying over the past five years. 77 were neonatal deaths and 147 were stillborn. Ten mothers also lost their lives. Despite 96 SAERs, none were published with NHS Lanarkshire citing data protection laws. NHS Tayside, which says less than five babies and five mothers have died in the last five years, also refuse to publish because 'disclosing information about such events could lead to patients becoming identifiable and this would breach Data Protection Principles.' NHS Grampian held 63 SAERs into neonatal deaths, stillbirths and mothers dying since 2019, but these have not been published. It reported 152 baby deaths, 61 neonatal and 91 stillbirths, saying less than five mothers died in each of the last five years, adding: 'Not every death resulted in a report being produced.' The Scottish Government said: 'We are currently meeting with leaders from all boards as part of a programme of work to improve SAERs, and HIS have recently published their updated national framework for the wider adverse event review process.' NHS Lothian medical director Dr Tracey Gillies said: 'Every death is a tragedy and, in line with national guidance, a full review is carried out to investigate unexpected or potentially avoidable events to understand and where possible implement actions to prevent similar incidents in the future.' A series of failings Scotland's biggest baby death inquiry criticised NHS Ayrshire & Arran over six deaths. They included the November 2015 death of Fraser Morton's son, Lucas, who was born on a night when a third of staff were found to be absent. A series of failings contributed to Lucas's birth including the failure to monitor his heartbeat or to recognise his mother was suffering pre-eclampsia. Incidents examined in the inquiry dated back to 2008. © Andrew Cawley The inquiry found staff were unsure how to respond to SAER's once they were initially reported and the maternity unit at Crosshouse Hospital were circumventing reporting procedures to make themselves look better. HIS recommended the health board strengthen its adverse event management policy so it could be quickly and simply followed and improve engagement with bereaved families. Dr Tracey Johnston, chairwoman of the independent review group, said: 'There are clearly lessons to be learned from this review, not just for NHS Ayrshire &Arran but for Scotland as a whole.' A second major inquiry into the deaths of five babies at Caithness Hospital from 2010 sparked major changes to the community unit which had no facilities for on-site neonatal paediatric support or adult intensive care, resulting in mothers being sent to Raigmore Hospital in Inverness. Following criticism of the proposed changes, Dr Rod Harvey, NHS Highland's medical director, said the midwife-led unit at Caithness General would be able to identify problems in pregnancies at an early stage, and that pregnant women who had to be transferred would be moved in a 'calm and collected way'.
