Ombudsman calls for national system for reporting adverse incidents in Scotland

A standard system is needed to record adverse incidents across the NHS in Scotland to improve the care of patients, the country’s public service ombudsman, Jim Martin, has said.

His request comes after a BBC investigation found wide discrepancies in what were considered to be adverse incidents and how they were reported. They ranged from fatal medication errors to a nurse being injured while hanging Christmas decorations.

The investigation was based on freedom of information requests to all health boards in Scotland asking for the number of adverse incidents they had identified in the past year and how these were reported.

In a report broadcast on 26 November (www.bbc.co.uk/programmes/b01p6w7y) the BBC said that it was given reports of 345 incidents involving more than 100 deaths. Shetland, one of the smallest of Scotland’s health boards, recorded 138 serious incidents, while Greater Glasgow and Clyde, the biggest, admitted to only 95.

This variation in what is classed as a serious incident and what is being recorded is a concern, said Martin, who investigates complaints in the NHS. “I think we’re pretty confused about what we call things, what things mean and whether, for example, a critical incident review is a health and safety review, [or] whether it’s a review of something that’s gone wrong surgically, or in a GP’s surgery, or in a dental surgery,” he said.

“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.”

Martin has been supported by Scotland’s health secretary, Alex Neil, who has called for greater consistency. Neil has asked NHS Health Improvement Scotland to review the way that incidents are reported across Scotland as a matter of urgency.

Although the reports given to the BBC indicated failings in clinical care across a number of areas, the evidence shows that, overall, patient safety in Scotland is improving.

A patient safety programme that uses checklists to ensure that patients are given the best chances of survival is being implemented in every acute hospital in Scotland, after it demonstrated success in specialist areas. The number of unexpected deaths has fallen by around 20% in intensive care units and after surgery since the programme was introduced in 2008.1