SAERs - FOI Response Register

1. Annually, from 2007 to present, how many Serious Adverse Event Reviews (SAERs) have been conducted?

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

HIS give 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.”

From 01 January 2020, NHS Shetland (along with all other NHS Boards in Scotland) was required to report all significant adverse event reviews commissioned for a Category 1 adverse event to HIS.

All incidents listed in the table below had a SAER Level 1 Review         

* The records of incidents that took place prior to 2016 are paper-based and this makes it difficult to identify the exact the number and nature of any SAERs during this period. From the information we have available from this period, there were 2 possible SAERs in 2013 and one in 2014.

2. Please provide copies of each report covered in (1) 

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). Please see the Note below.

3. Please provide a brief description of the event that triggered each review in (1)

Please see the answer to question 2

4. Please provide a brief description of the findings of each review in (1) 

Please see the answer to question 2

NHS Shetland confirms that all Reviews had action plans developed and progressed to address any issues of concern identified during the conduct of the reviews.

Note

Due to the nature of these SAERs and the small numbers involved in a remote and rural population, NHS Shetland believes that providing a breakdown of the year of the adverse event, together with a brief description of the event and copy of the SAER report (even if redacted) creates a significant risk of individuals being identified.