The NHS - learning from mistakes?

Doctor looking at notes

Last year, the Scottish Information Commissioner criticised how NHS Ayrshire and Arran had handled Freedom Of Information requests for Critical Incident Review reports and Significant Adverse Event Reviews. It transpired that these reports had simply been buried.

The resulting outcry led Health Improvement Scotland (HIS) to carry out a review and in June 2012 they recommended that NHS Scotland :-

• Develop a consistent agreed approach to the investigating, reporting and learning from significant adverse events and

• Maximise the opportunities for NHS Boards to share and learn from significant adverse event reviews.

As a result, HIS has now issued a consultation paper on building a national approach to learning from adverse events through reporting and review.  The consultation document can be found on the HIS website

Responses are requested by 1 March with a view to presenting government with an agreed approach by Spring 2013. 

It has always been rather a lottery as to whether significant adverse events generate an investigation.  This certainly happens more often then it used to but the lack of consistency has always been troubling.  The quality of reviews when they are carried out is highly variable.  This initiative through HIS is very much to be welcomed as a step forward in improving learning and reporting across NHS Scotland.

Whether or not it does anything to address the problems highlighted by the Scottish Public Service Ombundsman (SPSO) to Scottish Govt recently remains to be seen (

If we can’t change the culture of secrecy and defensiveness towards complaints within the NHS – and successive SPSO’s have raised this issue – is there at least some prospect of a robust investigation in all cases where things go badly wrong?