Severe Adverse Events Review - FOI Response Register

1. I would like to ask for the total number of Severe Adverse Event Reviews completed between 01/04/2018 to 24/11/2023.
2. Total number of miscarriages, new born or child (between 0-4 year old) deaths between 01/04/2014 to 24/02/2024 within Shetland NHS.

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 NHSScotland 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 were 2 significant adverse event reviews held over the time period 2018 to 2023 (9093 and 8062)

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.