Health and Sport Committee

Meeting date: Tuesday, December 12, 2017

Official Report 563KB pdf

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NHS Governance

Agenda item 2 is an evidence-taking session on NHS clinical governance, and I welcome to the meeting Fraser Morton and Ella Brown. At the start of the committee’s work on this issue, we heard from Fraser and Ella at an informal evidence session in which NHS patients told us about their experience of the NHS. I thank both of you for coming along that morning and, indeed, for coming along this morning, too. Your willingness to share information on such difficult and emotive personal experiences is greatly appreciated by all of us on the committee.

Before we begin, I will provide a brief introduction to both your experiences. Mr Morton’s baby son Lucas was stillborn at Crosshouse hospital in Kilmarnock in November 2015, and Mr Morton and his wife June were among a number of families who called for a public inquiry into infant deaths at the hospital’s maternity unit. The Cabinet Secretary for Health and Sport subsequently instructed an investigation by Healthcare Improvement Scotland into the management of adverse events in the maternity unit. The report from that investigation, which was published in 2016, made a number of recommendations for NHS Ayrshire and Arran and, indeed, the whole of the NHS in Scotland.

Ms Ella Brown lost her father following a fall at Victoria hospital in Fife. Since then, she has worked with the NHS board to bring about changes aimed at reducing hospital falls, including the “Falls call to action” events, which have brought together staff, patients and carer expertise with the aim of reducing by a fifth the incidence of harmful falls through improving practice, patient care pathways and the hospital environment in general.

In recent weeks, we have taken evidence from a range of stakeholders on NHS clinical governance, and we were keen for both Fraser Morton and Ella Brown to have a further opportunity to speak to the committee and to comment on the themes and issues relating to NHS clinical governance that have been raised at our evidence sessions.

We will now move to questions, and we will probably try to wrap things up by about 20 minutes to 1. Once again, you are very welcome to the committee, and thank you very much for coming.

Thank you very much for coming this morning and for all the very helpful evidence that you have provided. I know that you are following the committee’s evidence very carefully, and in my first question, which is specifically for Mr Morton, I want to refer to evidence that we recently received from Professor Leitch.

Professor Leitch confirmed that there is no central monitoring of serious adverse events and suggested that their

“definitions are so broad and varied”

that centralised reporting might not actually be helpful. He also believes that

“We have to rely on the boards to have processes in place such as clinical quality committees and regular morbidity and mortality meetings”.—[Official Report, Health and Sport Committee, 28 November 2017; c 20.]

so that individual clinicians can discuss cases. How do you feel about those comments?

To be honest, I do not understand them. My understanding is that there is a national framework for adverse events, which came out in 2012 or 2013 and has recently been updated, and I believe that there should be some standardisation of what such events are.

Since its review of NHS Ayrshire and Arran in 2012, Healthcare Improvement Scotland has described adverse events as the “springboard” for driving improvement to ensure that they do not happen again. If that is the case, there should be some sort of standardisation to help us identify not only adverse events but any recurring themes or trends in Scotland.

The fact is that statistics are not being collated. We were told at a meeting with an HIS review team that everybody is basically doing their own thing, despite there being a national framework in place. Some sort of methodology or standardisation has to be put in place to allow us to collate statistics so that we can address the matter and target our finite resources. When we talk about adverse events, we are basically talking about things that have gone badly wrong and about fatalities—they are not just statistics.

From what I know from NHS Fife, adverse events were always just one thing rather than all these different things. I have no problems with what NHS Fife is doing; I see all the monthly falls reports from every ward and every hospital in Fife, and I can see that things are improving. There are blips and ups and downs, but you can have too many charts and different things. This is not about paperwork; it is about people—nurses, doctors and everybody—speaking to each other and working together. Nurses are complaining about having to do too much paperwork and having to spend half their time filling in forms, and we need to get back to a hands-on approach.

I have no complaints about NHS Fife, but the last time that I was here, I heard different things. Not all the health boards are working the same way, and there are great gaps between what is good and what is bad. However, you will never get everybody in Scotland singing from the same hymn sheet—that will never happen.

To what extent are inadequate staff levels or staff training a factor in things going wrong in the NHS? For example, I am very much aware that the campaigning that Mr Morton and other families have done will ensure that multidisciplinary cardiotocography—or CTG—training is made mandatory.

Staff training and staffing levels were not good when my father fell and fractured his skull. After I started to work with the NHS, I had a campaign, and we got six more ward nurses who were funded by the Government. A lot more funding is going into things like that, but the issue is one of staff levels.

Mr Morton, staffing levels seem to have increased markedly as a result of the work and the campaigns by you and other families. Can you comment on that?

On staffing levels? On the evening our son died, we were initially told that staffing levels in the maternity ward were short by 30 per cent.

Going back to the issue of missed opportunities, I think that if you correctly monitor, collate and—to use the buzz phrase—drill down into adverse events, you should be able to identify recurring themes. One recurring theme is inadequate staffing, and I can give you an overview of that. The “Each baby counts” campaign identified that a lack of resources can contribute to one in four stillbirth or neonatal deaths. That is a national figure, but there is a problem with staff levels and resources. I should also point out that, over and above the adverse events statistics that are produced, a programme called MBRRACE-UK—it stands for mothers and babies: reducing risk through audits and confidential enquiries across the UK—produces stillbirth and neonatal death statistics.

In 2013, NHS Ayrshire and Arran was one of the worst boards in the UK, if not the worst in mainland UK; it was second only to Belfast Health and Social Care Trust, for obvious reasons. Because of those statistics, the board was red flagged, which committed it to doing an internal review and investigation. I have read that internal investigation, and I found it to be very outward looking. It took a scattergun approach, looking at multiple deprivation, drug taking, obesity and smoking; indeed, it looked at everything apart from the board itself. It was not inward or introspective, and I believe that it was an opportunity missed. That investigation was conducted in 2015, because of the lag in collating statistics and so on.

Only two years later, as a result of the recent HIS review, we have in place 16 additional midwives, two sonographers, one additional consultant and a labour suite risk management midwife—or something to that effect. That is a huge number of staff, and such a requirement could and should have been identified earlier. If the adverse events had been collated and monitored properly and if a proper investigation had been done into MBRRACE’s red flag figures in 2013, those shortcomings could have been identified earlier, as they should have been.

12:00  

Good morning. I wanted to ask about your feelings with regard to levels of accountability for boards. Over the past few weeks, we have heard that boards are investigating serious events or other types of complaints and responding to them themselves without much higher-level involvement. Are boards being held sufficiently to account for what they are delivering?

To be honest, my quick answer would be no. NHS Ayrshire and Arran defines clinical governance as

“a statutory obligation”

and

“a framework through which”

the board is

“accountable for continuously improving the quality of their services and safeguarding high standards of care by creating an environment in which excellence in clinical care will flourish.”

If that is a statutory obligation, I have not, despite my best efforts, been able to establish which piece of legislation covers it. Moreover, if the board is indeed accountable, I do not know whom it is accountable to.

I can talk only about our own circumstances at NHS Ayrshire and Arran. Looking back, the terms “clinical governance” and “adverse events” were alien to me and my family until November 2015, but I quickly became aware of the intervention by the first of three cabinet secretaries in 2012 and the first of three HIS reports in 2012. Going back further still, in 2009, NHS Ayrshire and Arran admitted to difficulties in applying its management of adverse events policy. I can take you back even further: I have looked at action plans going back to 2006 that were produced on the back of adverse events, and I was shocked to see the same themes and trends and the same failings in care with regard to staffing, training, handover and communication. Those were the same areas that failed Lucas in 2015.

In the intervening period, we have had the intervention of three cabinet secretaries. In 2012, Alex Neil challenged the non-executive directors of NHS Ayrshire and Arran and the wider NHS Scotland to apply a greater degree of scrutiny to the executive management team. There was also an investigation by what was Strathclyde Police into 40 suspicious deaths in Ayrshire and Arran.

On top of that, according to Jason Leitch, the Scottish Government collates or looks at the adverse events statistics by going through health board papers, although, as someone point out, it is difficult to lift that information out of a 500 or 600-page document. If that is indeed the case, I do not know how the Government missed the fact that NHS Ayrshire and Arran was averaging 19 adverse events per year, which, as Robbie Pearson stated in his report in 2012, was low. The following year, the figure was zero. That was happening during a period when there was supposedly a national framework and supposedly greater scrutiny by the Scottish Government. You would like to think there would be greater scrutiny by the actual board of the health board and by HIS, which helped to implement the policy, but the issue was missed for three years.

I have worked a lot with patient relations; indeed, that is how I got to know the health board and all the things that are going on. I see all the reports. I work with patient relations a lot, and I think it is doing fine. It is five years since my father died, but we are moving on all the time. I have spoken at conferences and have done all sorts of things; I have got the issue out into the public domain; and I have spoken to people and got them to speak to each other. What I do is a hands-on thing; I do not know figures or facts—I just work on my own initiative.

I was so angry when the incident happened, and I felt that I had to do something. That is why I started, and I just did it. I still feel driven to do it; that is my way of approaching things. It is all about speaking to people and keeping the issue in the public domain. My experience with NHS Fife is that it is working very hard on patient relations, and it is doing a major amount of work involving all the different departments of the board. Nothing is perfect, but the situation is much better than it was five years ago, and it is still improving.

Mr Morton, I want to follow up on your last answer. Do you think that the boards should have less discretion over how they manage such events? Should there be some other way of managing them, and would it involve more central control over the boards? How would you visualise that?

I am not sure. I am not a healthcare professional, but the board and the senior management of NHS Ayrshire and Arran obviously missed an opportunity. However, in Ayrshire and Arran, things work through a kind of silo system of clinical directorates; matters are progressed to the risk management committee, which I believe is chaired by the chief executive officer of NHS Ayrshire and Arran; and the adverse events are then put forward to the healthcare governance committee, which I believe non-executive directors of the board sit on. Whether or not it involves an adverse event, the final decision is taken by either the medical director or the nursing director.

The system is in place, and things in Ayrshire and Arran have definitely improved. Back in 2012, however, an opportunity was definitely missed by the executive management team and the board; it was missed by the wider NHS Scotland and the Scottish Government; and it was missed by Healthcare Improvement Scotland. Nobody was collating the information. Such events might be the springboard for driving safety and improvement, but you cannot improve what you do not measure. The statistics were not even being collated. If you look at the disparity in the figures throughout Scotland’s 14 health boards, you will see clearly that there is no standardisation and that the national framework is not being implemented.

I bring it to the committee’s attention that Mr Morton is a constituent of mine and I have been working on his specific case.

Good morning, Mr Morton and Ms Brown. I want to ask about the HIS investigation. Do you reckon that it was instructed in response to the media attention, or was the Scottish Government already aware of and managing the issue?

I found the failings to be so deep and widespread in NHS Ayrshire and Arran that we, as a family, circumvented the complaints policy, you could say. I wrote to the medical director and the CEO, but the response was not what I had hoped for. I then wrote to the health secretary and got a response from someone in her office. I wrote again. Reluctantly, after a year of trying, I wrote to everybody. During that period, I was dealing with the Scottish fatalities investigation unit. We reluctantly sought media attention and, as far as I am concerned, the intervention was initiated only after the adverse media publicity.

Regarding the HIS review, is HIS fit for purpose in this arena?

The neat answer is no, but I will expand on that a wee bit. We have had three HIS investigations in Ayrshire and Arran. The first was in 2012 and the follow-up was in 2013, which missed the fact that NHS Ayrshire and Arran had already decided to circumvent the recently embedded management of adverse events policy. Its decision to do that basically negated any chance of learning from the failings and of putting measures in place to prevent them from happening in the future.

It is interesting that, in 2017, HIS stated that it expected material progress to have been made since the previous failings were initially identified, in 2012. You might not be aware of that comment, because it was in the draft report that I received through a freedom of information request and it never made the final report—I do not know why. You can judge for yourselves why that comment never made the final report.

I do not know about HIS, but I have previously described its mission creep. It is like the Acme of NHS Scotland. It has a wide remit and it is taking on too much.

I want to ask something about both your cases. There were guidance and standards that medical staff were supposed to be guided by, which I presume were not adhered to. You then raised a complaint. Did you do that at a ward level first, or did you go to a higher level initially? Did you go straight through the complaints process? Was the complaints process adhered to? Was there a failure in the guidance or in the complaints process? Ultimately, how did you get to bring about a change?

I did not go through all the committees or do the different things that Fraser Morton did. My father was in the ward for a hip replacement when the Victoria hospital changed over from the old to the new, and there were a lot of problems with that. When he was in that ward, I could see that it was totally understaffed. I told the staff that my father would wander, and they said, “Oh, yes,” and other things, keeping it short. I told the nurses, “Watch him—he’ll wander.” The short story is that they did not watch him and, the next night, he got up, went to the toilet, fell and fractured his skull, so he died.

I was very angry at the time. The staff were very good with me, with different people helping me. I went home for about month but it was no good. It was getting to me, and I felt it would destroy me if I did not do something about it. The social worker who had been my dad’s social worker told me that I could write to a new service that had just started, which was called patient relations.

I was hurt that, during that month, nobody had contacted me, come to the funeral or done anything at all—I was just abandoned. I wrote a six or eight-page letter—I poured the whole lot out—and sent it off to patient relations on a Monday night. On the Tuesday morning at 9 o’clock, I got a phone call from someone at patient relations. They were absolutely horrified at what had happened. I started working through patient relations—it was all done through that service.

Is patient relations part of NHS Fife?

It is part of NHS Fife, but it is independent. The people there look at the situation from both points of view and take people’s complaints to the higher-ups. That is where it all started.

But is it—

It is not a totally independent organisation, but its staff care about the patients and what has happened. It is a sort of buffer between the public and the health board.

Initially, when the incident happened and you were, I presume, horrified at what had happened, did you raise the matter with the ward management?

Yes, and the doctors came and spoke to the nurses.

The issue was largely dismissed, was it?

No, it was not dismissed. They dealt with it, but I saw that there were a lot of problems that had to be addressed and I wanted to address them. The staff did what they could and were very sympathetic. It took 10 days for my dad to die, and they were very good during that time, but I knew that there was a big gap and lots of problems. I just felt so angry, and I wanted to address the problems.

Regarding the complaints process, within hours of Lucas dying, I was really uneasy about what had occurred so I did a bit of research. I came across the 2012 review and, according to the papers, NHS Ayrshire and Arran had been accused of suppressing adverse events. I downloaded the management of adverse events policy and familiarised myself with it.

I must say that the care that we got from individual staff following Lucas’s death was second to none. It was great—I could not fault it. We were assured that the matter would be taken very seriously and that there would be a serious investigation. What spurred things for me—the final straw—was being given a death certificate that stated “unknown”. Following previous family deaths, I was aware that certain deaths have to be notified to the Crown Office—to what is now the Scottish fatalities investigation unit. I quickly made a call and the staff I spoke to had no record of Lucas’s death.

That resulted in me and my partner, June, being interviewed by two police officers. We were actually split up. That was within weeks of Lucas’s death, and we were split up in our own home. I have no complaints about Police Scotland—it is just the process—but it was awkward to give our statements in that way. Lucas’s death should have been notified to the Crown Office. I can pick up on that point later.

I lost all faith in the complaints process, which is what initiated my complaints at a higher level. That is why I circumvented the complaints process. On the basis of what I had learned about the history of NHS Ayrshire and Arran and what I perceived to be shortcomings in the notification of our son’s death, I took the matter to the board and further afield, into the political domain.

12:15  

I thank both of you very much for coming along this morning. It is commendable that you are pursuing your respective issues, which I hope will generate benefits across the whole health service.

I want to compare and contrast. I am sure that there are shades of grey here, but, looking at your situations from the outside, it looks as if there have been two tragic events. In your case, Ms Brown, after a while, NHS Fife has embraced your perspective of the incident and has involved you in the process. From what I have seen, the board is making significant progress and the processes and procedures are changing for the benefit of everybody. In Mr Morton’s case, however, we see the opposite. If I am not mistaken, you seem to be have been kept at a distance, Mr Morton, and the outcome in your case has been more confrontational. Is that a fair comment? Do we think that it comes down to the different leadership in the respective health boards and how things have been viewed from their side?

I think so. The staff in Fife were shocked and horrified at what had happened, and they were very kind to me in different ways. There was a police investigation and all the rest of it. The staff did not put up any barriers—I was welcomed in from the first minute, and I said that I wanted to work with them. I got letters and phone calls and so on from people, and they said that I could come and work on their committees. They changed all the boards and did lots of other things. They took me round to let me see everything. Five years on, I am still working with NHS Fife in different ways and on different committees.

At the time, NHS Fife was battered daily in the papers about everything. I thought, “This has to stop. Somebody has to do something about it.” That was I why I tried to get the staff and the public—everybody—to work together and talk to each other instead of putting up barriers and being frightened of each other. That has worked.

Has that been your experience, Fraser?

What Mr McKee said is a fair comment, although things have changed as recently as yesterday, when I met John Burns from NHS Ayrshire and Arran. I would like to think that the board is now turning a corner. It would have been a fair comment until very recently, because that was our experience: we were definitely held at arm’s length from the process. We received a root-cause analysis report of 12 words. The summation was: “We could not find a root cause for this event.” That is what Lucas’s death was—an “event”.

That is where it would have been left. His cause of death would have been “unknown” according to the National Records of Scotland, and the hospital did “not find a root cause for this event.” It is only through our efforts—which have really taken a toll on me and our family—that we have got to where we are.

Are you saying that there has been a change in attitude or communication in the past few days?

It was only yesterday that I met John Burns and a member of the board.

I wonder why that was. May I suggest that it is no coincidence that you are appearing here today and Mr Burns was here last week?

I am not going to speculate.

Yes, let us not speculate. It is good news that things appear to be moving on. What came out of that conversation, if you do not mind my asking?

Mr Burns gave me an overview of the implementations and the changes that the board is making. I believe that it is putting things in place over and above the recommendations of the HIS review and the commitments by the cabinet secretary and the chief medical officer to make multidisciplinary CTG training mandatory.

According to the national figures, the medical legal costs relating to CTG are huge, and it seems to be a false economy to scrimp on it. That has not always been the case. CTG training was all but abandoned in NHS Ayrshire and Arran due to insufficient staffing numbers. I got that confirmed, again through a lengthy FOI process. I had to appeal to the commissioner to get that information. The training was abandoned for 13 months, from December 2015, the month after Lucas died, when we were told that it would never happen again.

Significant changes have been put in place, and I believe that the board is trying to embed, as mandatory, a training package called PROMPT—practical obstetric multi-professional training—which is internationally recognised for improving outcomes and reducing the number of fatalities.

I welcome you both to the committee. Over the course of the work that we have been doing, the work that you have both done has been shown to be making a huge difference, specifically in those hospitals where the incidents occurred. They related to the culture of our health service—a matter to which we keep returning—in which some incidents are covered up or not really engaged with because they are seen as failures. I am interested to know your personal views about the culture, having seen it and having seen it change in both your cases.

When the incident happened, NHS Fife was absolutely terrified of the suing society. People would admit to nothing, say nothing, not talk to anybody and not raise their heads above the parapet in case somebody sued them. I said right at the beginning, though, that I had no interest in suing anybody, as money would not bring my father back; I wanted to improve things. That made a difference.

The board has got braver as the years have gone on, and there is a totally new atmosphere in NHS Fife. I can only speak about going backwards and forwards to the Victoria hospital. You go through the front door now and it is totally different. I have done training videos with people and I have worked on duty of candour videos. I have been asked to speak at conferences and to get staff to work together and do training on how the patients feel from their own perspective. I have no complaints about NHS Fife at all. We are all learning all the time.

How has the management in the health service specifically changed, as far as you can see? It is very much front-line staff that you have referred to.

I have worked with both front-line staff and all the senior directors of nursing. I work with higher people, too. They have all changed—they are all much more open, and I have not found any problems. Tricia Marwick is now in charge of the board, whereas it used to be Allan Burns, but I do not see any difference: it is still working in the same way, going forward all the time.

Good.

In reference to what Ella Brown has said about the legal culture, I must say that our experience was somewhat different. We were challenged to sue—that is the best way that I can describe it. We were actually challenged: “Why don’t you just sue us?” That was in response to difficult questions that we were asking about the failings surrounding our son’s death.

I have two supplementary questions for Ms Brown. First, why do you think the culture has changed? You alluded to the NHS board chair having changed and that not having had an impact. What do you think has been the impetus behind the shift in culture?

Secondly, do you think that what happened to your dad could happen again, or are there structures in place, or have changes been made, that make you feel confident that it could not happen again?

I do not think that it could happen again, given all the different measures that the board has put in place and what I have seen to prevent falls—from coloured wrist bands to falls protocols and all sorts of other things. We meet every two months and we see those things happening.

When I talk about things not changing, I do not feel that there has been a backward step or that issues have been ignored or shoved in a drawer and forgotten about while the top management has changed. The issues are still on-going. All the committees that I am involved in are still on-going, and there are a range of people on those committees, including geriatric clinicians. The doctors are all coming on board with the nurses, and it is all working amazingly well. I am not saying that it is perfect—nothing is perfect—but the situation is improving. I am quite confident about that.

I have a question about all the practical things—the real things—that have happened. We hear a lot of people say, “We all work together.” However, when we ask them what working together means, they sometimes cannot tell us. What practical things have happened in the wards that increase your confidence that such incidents could not happen again?

My father was in the early stage of Alzheimer’s, but he also had a fractured hip, so he was put into an orthopaedic ward. Many of the orthopaedic nurses were not used to dealing with elderly people with dementia and other conditions, so the board started to bring in dementia nurses, and call bells and all sorts of other things were introduced. That change is still happening. The board has evolved in that way, with different areas working together.

Were there changes within systems that had to be rolled out?

Yes. All the hospitals in Fife work within the same systems.

Did that require a whole module of training for people?

Yes. People were brought in to give training, including from the psychiatric hospital at Stratheden. St Andrews hospital is different from Victoria hospital, but the staff were all given training, with training managers and training plans set out. I saw all that for myself. The plans were all sent to me to be scrutinised.

Excellent. That is good. You have told us more about how some of these things are rolled out than some senior managers and senior executives.

I am a people person. I do not read brochures; I just talk to people. I watch and I pick up things.

We could perhaps do with you as the chief executive of an NHS board.

Well, I am available.

Thank you for coming today. You have described how the culture has changed in both places, even if it is a recent change in Ayrshire and Arran NHS.

My background is in clinical education and nursing. I know that there are learning modules about falls prevention in the community and in acute care. There will be development of and roll-out of training, whether face to face or otherwise. Delirium assessment occurs in orthopaedic units now. I am interested in how you see the national picture evolving. How would you spread the best culture nationally across all boards?

The culture is really improving: I do not think that anybody is arguing against the idea that a culture of continuous learning and improvement is the way to improve patient safety and the quality of care. However, I see no reason why that cannot happen within a regulatory framework, which is currently missing. Regulations set goals and objectives and come into play when the objectives and goals are not achieved—which I believe was the case for Ella Brown and me. People’s behaviour is governed by regulations.

Currently, however, I do not believe that there is a regulatory structure for when the culture of improvement and learning falls short of achieving its goals. I would like something like that to be put in place. How it would be done, I do not know, although nobody is asking for an organisation like the Care Quality Commission to be uplifted and embedded, warts and all, within NHS Scotland. Some people and some organisations need to acknowledge that we have a Scottish problem for which we need to find a Scottish solution.

Emma Harper has, largely, asked about what I was going to focus on.

Succinctly, are you confident that lessons have been learned in your health boards with regard to the terrible circumstances that you encountered? Are you confident that that learning has been passed on to every one of the 14 health boards in the country, or is it a victim of the silo culture—which the committee has repeatedly encountered—of the 14 health boards, where what works for one is often not replicated in others? Are you aware of how much best practice has been passed on?

From what I have heard at the committee, from speaking to MSPs before meetings and from what I have heard about other people trying to complain, I do not think that best practice has been passed on. For example, at Ninewells hospital people cannot get anywhere. I can really speak only from my experience in Fife, but I do not think that best practice is being passed on. There is still a long way to go. I have suggested to people that they should call patient relations departments and they will help, but some boards seem not to have patient relations departments. There is a long way still to go.

On NHS Ayrshire and Arran, I do not understand how an organisation that had admitted to having serious problems with its management of adverse events was allowed, in 2012, to formulate and try to bed in its own policy on adverse events. I believe that it is the responsibility of Healthcare Improvement Scotland to create a culture of learning across the whole of NHS Scotland. That did not happen in that case.

Adverse events, which I have looked into in great detail, are not collated in a standard way by Scotland’s 14 health boards, and they are not routinely monitored by Healthcare Improvement Scotland. I do not believe that the greater NHS Scotland or the Scottish Government—I am not sure which it would be—looks into that by monitoring boards’ papers. I do not think that that would be possible. It would be an untidy and awkward way of getting what should be a simple collation of figures to drill down into and to use for greater learning. You have tripartite failings.

Going wider, if we look into deaths such as Lucas’s, the Crown Office does not even collate the number of deaths or look for themes, patterns or trends in the deaths that are notified by each of Scotland’s health boards to the Scottish fatalities investigation unit or the Crown Office.

12:30  

On other deaths, we go back to HIS, which has a death certificate review service. There were 57,000 deaths in 2015, for example: more than 47 per cent—roughly 27,000 deaths—of the death certificates were found to be not in order. I think that it would be fair to suggest that some of those 27,000 death certificates would have met the criteria for notification to the Crown Office, based on the guidelines that have been issued by it. I have an FOI request pending on whether that is the case, and whether any of those 27,000 deaths have been retrospectively submitted to the Crown Office for greater scrutiny. I will not go into great detail, but looking back into the findings of the Shipman inquiry, that is something that we need to have in place. That would be an important safety net, that I believe is missing from our society.

You mentioned 27,000 deaths. Over what period was that?

That was in 2015. It was 47.1 per cent of deaths. This is about medical certificates that are sent to National Records of Scotland. Since 2015 there has been the death certification review service, under the umbrella of HIS. I do not know what happened before then, if anything. It examined a sample of 5 per cent of certificates from 2015 and found that, of those, 47.1 per cent were not in order.

Is that work being continued?

Yes. In 2016 the figure fell slightly, to just below 40 per cent. I do not know what processes and improvements were put in place to drive that improvement, but it fell to 39 point something per cent in 2016.

Within that, has the service identified issues?

Well, this is the thing: if adverse events are a springboard from which to drive improvement, and if you consider patterns—

No—you are talking about inaccurate death certificates.

Yes.

So, has the service identified what the inaccuracies were?

No. That was not in the document that I looked at.

That is helpful. Thanks.

I should have noted at the start that I have a relative working in NHS Ayrshire and Arran. I apologise for not saying that earlier.

It is interesting to hear about two completely different experiences. The key thing for me is the implementation of recommendations, once we have them, having drawn on reviews and your experiences. Can you highlight the differences in how investigations have been conducted? I am very aware of Fraser Morton’s case, but Ella Brown seems to have had a much better experience. For me, that is the key.

Yes, I did. I wanted to bring that to people’s attention the last time I came to committee, and to prove that I had had a much better experience. I was abandoned for the first month but, after that, I was much more accepted. I have done what I wanted to do, and I am still doing it. I have been taken on to do interviews for patient relations jobs, and so on. I like to do things like that and to offer the public’s perspective.

I feel that the board is much less frightened of being sued now—it has come out from behind its barrier and is getting in touch with the public.

So, your experience of implementation of the recommendations was very positive.

Yes. It has all been very positive.

Mr Morton would perhaps say something slightly different.

I thought immediately they were announced that the terms of reference of the recent review are too narrow and the timeframe is too short. The timeframe was based on improvements that had been made by NHS Ayrshire and Arran. One of the findings of the review team was it would expect material improvement. The terms of reference dealt only with the maternity service, but the adverse event policy covers every department. At this moment, we do not know the full extent of avoidable deaths within NHS Ayrshire and Arran. It is a common policy, but the board has concentrated on one small area.

Who set the criteria?

I believe that they were set by the Scottish Government, in conjunction with Healthcare Improvement Scotland. The timeframe conveniently missed encompassing the 2012 review. It is almost as if Healthcare Improvement Scotland did not want to examine its own part in the process. That is how it seemed to me.

I wrote to the Cabinet Secretary for Health and Sport and to Robbie Pearson. To digress a wee bit, there is a lot of talk in Parliament now about health and justice collaboration. I asked for the terms of reference to be expanded: I asked for a memorandum of understanding to include the Health and Safety Executive, the Crown Office and an expert in human factors. Specifically relating to our son’s death, one of the things that we were told was that people cannot see what happens inside a person’s head. We question why, for instance, my partner June’s case was not escalated, as per the guidelines. I therefore think that it is reasonable to request an expert in human factors.

The Health and Safety Executive agreed that there were systemic failures and failings in clinical governance—its view was diametrically opposed to that of the health board. The situation has just been left at that. The HSE agreed that there were clinical failings, and the hospital initially did not admit to any clinical failings. We just moved forward without anything being addressed.

The memorandum of understanding was reasonable—it was a feature of the Morecambe Bay inquiry—so I do not know how the remit of the recent review in Scotland could not have been expanded.

We have come to the end of our time. We greatly appreciate your coming forward. You have done your families proud, not just by giving evidence today, which is a difficult thing, but because you are pursuing issues that you care passionately about. We hope that that will change the system for the better, so that other people do not experience what you experienced. Thank you for your evidence.

12:36 Meeting continued in private until 12:59.