- 4 Feb 2019
Following allegations that a former Head of Neurosurgery at NHS Tayside harmed patients for years with no systems in place to pick up his mistakes, the Cabinet Secretary for Health and Sport wrote to all chairs and chief executives of health boards in Scotland to:
- seek assurance on the mechanisms in place for reviewing complaints of professional practice
- ask how they are assured of the safety and quality of the surgical practices of its employees
The responses are attached below.
Boards were asked to provide the following:
- mechanisms for the Board to detect and respond to clusters of complaints about the same clinician – with details of the process and timescales for this
- what arrangements are in place for ensuring timely decision making when the safety of practice of a Consultant is raising concern
Surgical safety and morbidity and mortality (M&M) reviews:
- ensuring that there is reliable delivery of process for pre-operative marking
- monitoring workloads, surgical list length and appropriately equipped theatres
- processes to support clinicians in presenting cases and have time allocated to attend morbidity and mortality reviews
- arrangements for reviewing the effectiveness of on-call rotas
Supervision of junior medical staff:
- consultant oversight supervision of junior medical staff
Openness and transparency:
- adescription of the processes in place to encourage open reporting and discussion of behaviours not consistent with NHSScotland values
- how quality of outcomes are monitored and any deficiencies reviewed and necessary action taken
The responses included several illustrative examples and also good practice examples in respect of arrangements in place to routinely consider and action similar issues to those that arose in NHS Tayside.
A workshop took place on 4 December 2018 which was facilitated by NHS Education for Scotland. Almost all territorial and special boards sent a representative.
The aim of the event was to consider the various examples of best practice that were reflected in the responses to the Cabinet Secretary for Health and Sport’s letter and explore opportunities to support learning, possible improvements derived from this learning and to be able to describe and evidence the effective implementation of this across the country.
We plan to build on this and to work with NHS Education for Scotland to identify how best to support the work of openness and learning, including an initial piece of research on what works and why.
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