- 10 Sep 2019
Adverse Events Management: NHS Board self-evaluation Report
Dear Carole (Carole Wilkinson, Chair, Healthcare Improvement Scotland)
I was pleased to have the opportunity to speak with you about the report that has been published on the management of adverse events within NHSScotland.
As you know, on the 3rd of September 2018, I informed the Health and Sport Committee that Healthcare Improvement Scotland would be undertaking this work to address the recommendations of their Inquiry report ‘The Governance of the NHS in Scotland’. Although I had expected this work to be completed by the 31st of March 2019, I am pleased to have now been able to consider this in detail.
I feel more action is required to address the inconsistencies that have been identified. We have one NHS in Scotland and I expect now to see greater consistency applied in the implementation of the national framework.
I am therefore writing to confirm that I wish to see the work required in this area to be given greater priority and, as such, have instructed Healthcare Improvement Scotland (HIS) to take forward actions that will require all NHS Boards to notify you when they have commissioned a Significant Adverse Event Review for a Category I adverse event. I would like you to work with NHS Boards to support them in standardising terminology and definitions, including the implementation across all NHS Boards of the consistent use of ‘Significant Adverse Event Review’. I expect that this will contribute to a more comprehensive national overview to be provided of an agreed number of defined ‘harms’ and associated learning and improvement actions.
Through this additional requirement, I expect HIS to be better able to articulate the ways in which your scrutiny, assurance and improvement support functions focus on ensuring that where permanent harm may have occurred, there is a continuously improving quality and consistency of approach – including the reliable and impactful delivery of any required changes and improvements to prevent future harm from occurring.
I have asked my officials to work with you to implement this further requirement to enhance national consistency and the proposed actions outlined in the baseline report.
I would also be grateful if you could ensure that your Board seek assurance that all relevant actions are being taken forward to confirm that there are more coherent local and national learning systems in place, systems that consider all available information as part of a wider quality management system. I expect the discussions with my officials about a collaboration between HIS and NHS Education for Scotland to be central to this further work.
I expect to receive further details and, in due course, personal assurance that arrangements will be operational from the end of this year for the new national notification, oversight, scrutiny and improvement support required.