Serious Adverse Event Reporting - FOI Response Register

Can you please provide me with the following information?

1. The number of SAER's carried out by NHS Shetland for the last three complete years (per year) that you have (i.e. 2020 to 2022).

1

NHS Shetland’s Learning from Adverse Events through Reporting and Review Procedure, which is based on Healthcare Improvement Scotland (HIS) Learning from adverse events through reporting and review – A national framework for Scotland (2019), identifies serious adverse events as a Category 1 event.

HIS provide the following definition of a Category 1 event:

“events that may have contributed to or resulted in permanent harm, for example unexpected death, intervention required to sustain life, severe financial loss (£>1m), ongoing national adverse publicity (likely to be graded as major or extreme impact on NHS Scotland risk assessment matrix or category G, H or I on National Coordinating Council for Medical Error Reporting and Prevention (NCC MERP) index”

NHS Shetland, along with all other NHS Boards in Scotland, are required from 01 January 2020, to report all significant adverse event reviews commissioned by the NHS boards for a Category 1 adverse event to Healthcare Improvement Scotland.

There was one significant adverse event review held over the time period 2020 to 2022.

In accordance with FOISA s 16(1), NHS Shetland confirms that it holds the information requested but that it is exempt from disclosure under FOISA s 38(1)(b) as read with s (38)(2A) as the information constitutes personal data and disclosure would breach the confidentiality of the data subject(s). The reasons for this decision are that, due to the nature of these events and the small sample size identified, within an overall small geographical population, NHS Shetland believes providing a breakdown of the year of the adverse event, age of the person involved, the location of their care and/or any further information contained within the adverse event reports, even redacted, will result in potentially patient identifiable information being released.

2. The number of copies of the final report for each Serious Adverse Event Review (full unredacted version) given out to review teams, staff directly involved in incidents, the patient, service user, family and carers) in relation to each SAER in the past three complete years (i.e. 2020 to 2022).

A presentation was given by the Investigating Manager, Subject Matter Expert for the SAER, to the Organisation’s Governance Group structure.  This included the findings and an improvement plan.  Due to the sensitivity and potential identifiable nature of this incident in our community this was an agreed way to inform the Governance Structure without reporting in-depth details.

The final report was issued to the relevant persons affected by the Significant Adverse Event.

3. An internet link for each health board's online published copies of their one page learning summaries for SAER's on their websites.

Due to the nature of this SAER and the ability to identify individuals involved within our small community it was not appropriate to publish the learning summary on the NHS Board website.  Actions were progressed by the Subject Matter Expert.