Latest news with #SignificantAdverseEventReview
The Herald Scotland
05-08-2025
- Health
- The Herald Scotland
No timetable for 24/7 stroke treatment as deaths hit eight year high
It came in the wake of the sudden death in June, 2023 of Tony Bundy from Clackmannanshire, who suffered a stroke whilst shopping at the Costco store in Glasgow. The family said he had to wait 17 hours for the surgery that might have saved his life and has been demanding changes to treatment in Scotland. In a response, after an appeal for action supported by four parliamentary shadow health spokespeople, Jackie Baillie (Scottish Labour), Sandesh Gulhane (Scottish Conservatives), Gillian Mackay (Scottish Greens) and Scottish Liberal Democrats leader Alex Cole-Hamilton, the health secretary, Neil Gray said that 24/7 access to treatment was an aim. He said they could not provide a timescale for when any 24/7 service would be operational but have asked for the work to be "carried out at pace with an emphasis on maximising equitable access". The Bundy family believe that treatment failure is costing lives and has said that 24/7 access to treatment should be prioritised and that there should be a timetable for any change. READ MORE: Why has treatment for strokes in Scotland become an issue? Revealed: 13,000 Scots oil and gas jobs disappear in a year - as UK relies on imports Row over £17.6m of public money spent on Scots sporting estate with 'no plan' It can be revealed that, according to Public Health Scotland data, the number of stroke deaths has risen from 2276 in 2015 to 2319 in 2023. There were 164 more deaths in 2023 than in 2022 when there were 2155 fatalities. An NHS Greater Glasgow and Clyde's Significant Adverse Event Review (SAER) into Mr Bundy's death from August of last year states that there is no night-time provision - between 8pm and 8am - for thrombectomy across any health board area in Scotland. James Bundy, late father Tony, mother Selena and sister Anthea (Image: supplied) And in 2023 it emerged that just 153 patients received crucial thrombectomy treatment - according to PHS analysis, which was just 1.4% of those who had an ischaemic stroke - the most common form. A thrombectomy is a surgery to remove a blood clot from an artery or vein and is used to treat some ischaemic stroke patients. Ischaemic stroke is the most common type of stroke caused by a blood clot cutting off blood flow to part of the brain. The procedure can restore blood flow to vital organs, like legs, arms, intestines, kidneys, brain or other vital organs. It can reduce the risk of death or permanent disability if performed promptly. Chest Heart & Stroke Scotland says the treatment can "vastly improve outcomes for eligible stroke survivors when administered within the recommended timeframe". They say those who have an ischaemic stroke and receive a thrombectomy are three times more likely to be able to lead an independent life. And they have said the Scottish Government should "urgently prioritise thrombectomy access" as it is a lifesaving and life-changing treatment" adding: "Equity of access must be a core principle of stroke care, regardless of where someone lives or when their stroke occurs." Three years ago, the Scottish Government's Stroke Improvement Plan emphasised equitable and timely access to diagnosis, treatment, and rehabilitation services across all regions. Neil Gray (Image: PA) And Mr Gray said in his response to the all-party group that a "commitment to a round-the-clock thrombectomy service" was set out in the plan and it "remains our aim". He added: "We all want a maximally expanded thrombectomy service, ensuring access to this treatment is as equitable as possible. This is a complicated piece of work requiring co-ordination across multiple hospital sites and professional groups and the utilisation of complex clinical equipment and facilities. "The work outlined... to align with wider NHS planning aims will inform the future expansion of the service and we expect this approach to bring a focus on shared solutions to challenges." There are now plans for a cross party meeting to examine stroke care in Scotland - although the Scottish Government has declined to meet with the family of Mr Bundy to discuss the issues further. Mr Gray added: "We consult with a wide range of stakeholders, including clinical professionals, third sector organisations and those with lived experience of stroke. We will always welcome the views of individuals, or their relatives, who have experienced the impact of stroke. However, it would not be appropriate to formally invite one family, out of the many thousands affected by stroke, to shape the implementation of policy." Mr Bundy's son, James, a Falkirk councillor, said: "I welcome the Government's aim to deliver 24/7 thrombectomy in Scotland, but an aim without a timetable is just a hope. Lives are being lost because this life-saving treatment isn't available overnight. My own dad had to wait 17 hours for a thrombectomy after his stroke. He didn't get the chance he deserved, and I don't want other families to go through the same. James Bundy with his late father Tony (Image: James Bundy) 'The NHS says thrombectomy is most effective within six hours. Yet not a single hospital in Scotland offers it between 8pm and 8am every day. There is already cross-party support for 24/7 thrombectomy by the end of the next Parliament. If the Scottish Government match that ambition with action, we can save lives. But we need a timetable. We need urgency. And we need to treat this as the priority it is.' Mr Gray's response came after a cross-party demand for 24/7 access to treatment. In a joint letter to the health secretary, they highlighted the urgent need to end the current postcode-and-clock lottery that leaves stroke patients without access to life-saving care outside weekday hours. They said: "Shockingly, some hospitals still do not provide thrombolysis services at all. These gaps in stroke care are causing catastrophic delays in treatment and, in too many cases, preventable deaths." They said that Mr Bundy's case was "unacceptable". NHS Greater Glasgow and Clyde says their services follow national guidelines, and that they fully support Scottish Government initiatives that aim to improve stroke symptom awareness. The Scottish Government was approached for comment.
STV News
27-07-2025
- 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
23-07-2025
- 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
