A FATHER whose baby was stillborn at an Ayrshire maternity unit has blasted the health board over its “flawed, rogue and ad hoc” investigation into his son’s death.
Fraser Morton also criticised the watchdog in charge of monitoring hospital care in Scotland as powerless and “not entirely independent of the NHS”.
He said an independent regulator for healthcare was required in Scotland to probe adverse events.
Mr Morton’s son Lucas died on November 16 2015 at Crosshouse hospital in Kilmarnock. The health board apologised over failures during the later stages of pregnancy to identify complications which contributed to the infant's "very tragic and unnecessary death".
The case was one of six so-called "avoidable deaths" over an eight year period at Crosshouse which triggered Health Secretary Shona Robison to order a review by Healthcare Improvement Scotland in November 2016.
It found that NHS Ayrshire and Arran had investigated serious incidents via its own Directorate Adverse Event Review (DAER) system rather than under the label of a Significant Adverse Event Review (SAER).
As a result it was able to claim that there had only been four SAERS involving stillbirth between 2008 and 2016.
In a submission to Holyrood's Health and Sport Committee, who are gathering evidence on clinical governance in NHS Scotland, Mr Morton said: "The statistical fallout of this approach was a 'false positive' of a far lower number of SAERs recorded across the entire board, which I believe was the management's aim from the outset."
He went on: "We as a family believe that their approach in suppressing the number of SAERS and replacing their policy with a flawed, rogue and ad-hoc replacement, has effectively negated any opportunity to identify failings and patterns and trends of such failings, and therefore increased the risk to patients whilst also effectively muting any opportunity to implement remedial action and positive change.”
However, Mr Morton said patients were also being let down by Healthcare Improvement Scotland (HIS), which he said "has no powers, and is not entirely independent of the NHS".
He noted that HIS "are on record as stating that they do not routinely received or monitor SAER figures, which begs the question who does?". He also questioned why NHS Ayrshire and Arran were allowed to develop their distinct DAER process in the first place, and urged MSPs to push for the creation of an independent healthcare regulator for Scotland.
He added: “The problem with the NHS in Scotland is that we have no independent regulator and therefore no rule and regulations. Senior management of HIS are on record as expressing reluctance and caution of introducing a regulatory regime to healthcare in Scotland. But we cannot continue to expect HIS to continue with their flawed ideological hands off holistic approach to the clinical governance of healthcare in Scotland. Speaking softly and not being armed with a big stick is clearly not working.”
John Burns, chief executive of NHS Ayrshire and Arran, said: "Following the Healthcare Improvement Scotland review into the Significant Adverse Event Review (SAER) process within Ayrshire Maternity Unit, NHS Ayrshire & Arran has taken forward actions to address the recommendations made in the review."
HIS said they have introduced a number of measures in recent years to improve the quality of adverse events reporting across Scotland.
A spokesman added: “Our organisation has extensive powers given to it by the Scottish Parliament to investigate and review services, and to escalate any significant concerns. We use a number of tools in order to bring about better care for people across health and social care in Scotland. Inspections and reviews, producing guidance and advice, plus the development of improvement tools, are just some of the ways in which we help to bring about better care. We also has the power to close wards when there are safety concerns.
"We will continue to develop new ways to bring about lasting and effective care for people in Scotland within the powers that we have been given. Ultimately, the chief executives of NHS boards are directly accountable to the Scottish Parliament.”
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