"adverse event"

About: NHS Ayrshire & Arran NHS Scotland

(as a relative),

My mothers consultant gave her three different dates to be discharged, however on the last date he gave her, my mother passed away. If this isn't an adverse event as laid down by the World Health Organisation, could some one please explain to me, what is?

Nothing was good about our experience and the family was not informed

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Responses

Response from Craig White, Divisional Clinical Lead, Directorate of Health Quality and Strategy, Scottish Government

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Dear Damocles13

Thank you for using Patient Opinion. I am sorry to hear about your mother's death and note with significant concern your comment on your family's experience. I think you may have been in touch with one of my colleagues in our Division, following which he advised that The World Health Organisation (WHO) defines an adverse event as "

An injury related to medical management, in contrast to complications of disease. Medical management includes all aspects of care, including diagnosis and treatment, failure to diagnose or treat, and the systems and equipment used to deliver care. Adverse events may be preventable or non-preventable." He thought that the Healthcare Improvement Scotland (HIS) publication 'Learning from adverse events through reporting and review: A national framework for NHSScotland' which provides definitions and categories that should be used to group adverse events across NHSScotland might be of some interest too.

The framework is available at:

http://www.healthcareimprovementscotland.org/our_work/governance_and_assurance/management_of_adverse_events/national_framework.aspx

NHS Boards all have policies on how they define, record, report and review adverse events. I am not sure what NHS Board was providing care for your mother and whether you have raised your questions and concerns with them? Scottish Government would expect that concerns of the sort you outline would be reviewed initially by the Board Medical Director in order to determine whether a delay in discharge has in any way contributed to your mother's death - which might then lead to the need for the sort of adverse event review that is outlined in the HIS document above.

Ideally this is something our colleagues in NHS Boards would want to be discussing with you in person, hearing first hand of the bad experience, noting your questions about the factors that may have contributed to your mother's death and working with you as they take action to ensure appropriate review of decisions, systems and care processes. If you are not already in contact with the Medical Director of the relevant NHS Board, I would be happy to provide you with the relevant contact details if this would be helpful. I can be contacted directly at Email: craig.white@scotland.gsi.gov.uk. If you prefer that I reply through the Patient Opinion site, I can also arrange for this.

Thank you again for making contact in this way. I can only imagine that your feelings following your mother's death are being negatively compounded by your understandable concern and need for answers about the sequence of events. We want to support you to be in touch with the right colleagues - which I will do all I can to facilitate for you.

Yours respectfully,

Professor Craig A White

Divisional Clinical Lead

Healthcare Quality and Strategy Directorate

Scottish Government

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Response from Craig White, Divisional Clinical Lead, Directorate of Health Quality and Strategy, Scottish Government

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Dear Damocles13

I am sorry that my response was not helpful - this was not my intention at all. I would be most grateful if you would consider letting me know, via Patient Opinion if it is easier than contacting me directly, how I can be more helpful in my response to your serious concerns.

Yours sincerely,

Craig A White

Prof CA White

Healthcare Quality and Strategy Directorate

Scottish Government

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Response from Gina Alexander, Director, Patient Opinion Scotland, Patient Opinion

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Just wanted to say that we didn’t attribute this story to the right Health Board when it was published, hence the reason for the response delay from them. We think we have resolved that now and apologies for our part in any confusion. We hope connections can now be made.

Best wishes

Gina

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Update posted by damocles13 (a relative)

Could some one please explain to me why,after so many people read my or any other persons postings,do not reply to them.

Does patient opinion refuse to allow them to comment,or is it, as I think,that the health board doesn't allow them to,whilst shouting from the rooftops about transparency etc.

Let the actual workers run the hospital.

Response from Eunice Goodwin, Patient Feedback Manager for NHS Ayrshire and Arran, Quality Improvement and Governance Team, NHS Ayrshire and Arran

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Dear Damocles13

Thanks for being in contact with us via Patient Opinion. Losing a loved one is always difficult but more so when you're angry with the care received.

The team at Patient Opinion have explained why it’s taken this time to alert us to your story. We can see Craig White has been in contact with you and appreciate his involvement.

I would be really keen that we can understand what went wrong, respond to your question and would be happy to be in contact with you and Craig if you feel that would be helpful. My contact details are: eunice.goodwin@aapct.scot.nhs.uk and 01563 826222.

With best wishes,

Eunice

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Response from Eunice Goodwin, Patient Feedback Manager for NHS Ayrshire and Arran, Quality Improvement and Governance Team, NHS Ayrshire and Arran

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Dear Damocles13,

Thank you for contacting me this morning. We had a long chat and I am so sorry you have had such a difficult time around your bereavement.

You raised a very valid question when you asked why each health board does not use the same Adverse Events policy, but a local version of the Heathcare Improvement Scotland document Craig mentioned in his response on the 3rd of February. Logic would imply it ‘should’ be the same policy but (I am led to believe) this is not always possible due to variations in how service is delivered. This is very much beyond my remit but I wonder if Craig White would be well placed to comment on this.

While we were chatting, I felt such overwhelming sadness from you which is so very understandable. It did make me wonder (as I said in our chat) if you and perhaps other family members could benefit from some expert bereavement help. I am aware you are reluctant to approach your GP but the GP or the GP practice could help to direct you. There is also a way to get help from our Service Lead for Listening and Support. I can provide you with that number if you wish. Alternatively, the charity - Cruse Bereavement Care can be contacted by calling 0845 600 2227 or on http://www.crusescotland.org.uk/ unfortunately, there are only meetings in Glasgow now as the Ayrshire Branch has been closed.

For clarity, I would like to mention that your post of 12th of April was held back by the Patient Opinion administration for some reason. My response on the 13th of April was posted prior to me being aware of your post. I would like to reassure you that A&A take all feedback very seriously and we are absolutely committed to a two way dialogue via Patient Opinion as appropriate. Either a member of the service or I myself always will always respond to posts on the Patient Opinion website.

I sincerely hope the chat today and this post is helpful to you and your family,

Best wishes

Eunice

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