SAERS - FOI Response Register

Scottish health boards were instructed historically that they must publish learning from SAER/CIR events and make this publicly available on their websites. It is your moral and legal duty, yet I cannot find this information.

1. Under FOISA can you please send me the links on your websites that will easily take me to this information?

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.

Within NHS Shetland we conduct a small number of SAERs every year and as such to publish these in the context of our island Board setting would potentially lead to the identification of individuals involved therefore we do not publish reports on our website.  In relation to FOISA requests re SAER reports the NHS Board generally notes an exemption under the clause noted below.*

*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, brief description and a copy of the reports, even redacted, will result in potentially patient identifiable information being released.

I can confirm that all SAERs conducted have action plans developed and these are progressed to address issues of concern identified through reviews.