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Vulnerable children still at risk after lessons not passed on

ERRORS in the care of some of Scotland's most vulnerable children could be repeated because lessons from serious cases are not passed on to frontline NHS staff, an investigation at the country's largest health board has warned.

A review of lessons learned from NHS Greater Glasgow and Clyde Child Protection Significant Case Reviews, which take place after a minor dies or is seriously injured and abuse or neglect is known or suspected, found there was limited evidence that learning points from the cases were flagged up to relevant health board staff.

The probe, carried out by consultants PwC, warned there was "a risk that knowledge and learning from incidents which have been investigated is not appropriately and consistently disseminated throughout the organisation, which may be ineffective in preventing similar instances in the future."

The findings follow an Healthcare Improvement Scotland (HIS) investigation into NHS Ayrshire and Arran, ordered by the Scottish Government, which found in June 2012 that there was confusion around the sharing of information between staff following reviews into significant adverse events, hampering learning and improvement, and recommended that the health board "undertake a fundamental review of its approach to sharing information".

NHS Greater Glasgow and Clyde said following the PwC review in September, it had taken steps to improve the sharing of learning in response to Child Protection Significant Case Reviews.

However, Dr Kim Holt, a paediatrician who formed the campaign group Patients First after she blew the whistle on unsafe practices during the Baby P abuse scandal, said NHS organisations often failed to learn from mistakes or share information as staff feared the consequences of owning up to errors.

"This is a national problem, so it's not surprising to me that there are these issues within Glasgow," she said. "If you're working in a organisation with a routine way of doing things, if something goes badly wrong people get very defensive and there is a reluctance to admit to mistakes."

Investigators looked at a sample of five of the 24 Child Protection Significant Case Reviews which been completed in the past five years in NHS Greater Glasgow and Clyde and the actions taken in response to the findings. They said a lack of formal dissemination of learning to staff presented a "high risk".

The probe also found NHS Greater Glasgow and Clyde staff were "unable to provide sufficient and robust evidence in the vast majority of instances" to show recommendations made as part of Significant Case Reviews were implemented fully.

The probe into how NHS Ayrshire and Arran handled critical incident and adverse event reports was sparked by mental health nurse Rab Wilson, after the health board refused to allow him the read the findings relating to an incident in which he had been involved.

Mr Wilson, who took the health board to the Information Commissioner who ordered the release of more than 50 NHS Ayrshire and Arran reports, described the findings in Glasgow as "deeply concerning".

Matt Forde, head of service for NSPCC Scotland, said it was "vital" that learning from reviews were "embedded in the work of all agencies" and that frontline staff should know about outcomes and what they meant for their practice.

A spokeswoman for NHS Greater Glasgow and Clyde said:"This report was commissioned by NHSGGC and it is important to note that the auditors highlighted in their report of September 2013 that a process was already in place which could be used to share learnings from Significant Case Reviews. In response to these findings we have further enhanced our protocols for cascading learnings throughout the organisation in response to Child Protection Significant Case Reviews."

Contextual targeting label: 
Health

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