Review of adverse events - Ayrshire Maternity Unit,
University Hospital Crosshouse, NHS Ayrshire &
Learning from adverse events
Healthcare Improvement Scotland has been asked by the Scottish
Government to undertake an independent review of the management of
adverse events within Ayrshire Maternity Unit at University
Hospital Crosshouse, NHS Ayrshire & Arran. The terms of
reference for this review can be found below. The review will be
independent, and our findings will be made public.
The approach that we expect to be applied in
managing adverse events is set out in
Learning from adverse events through reporting and review: A
National Framework for Scotland. This provides an
overarching approach developed from best practice to support care
providers to effectively manage adverse events.
The framework sets out that:
- All organisations should have a
management system for reporting, reviewing and learning from all
types of adverse events.
- The process must be transparent and
include all those involved in the adverse event: patients, service
users, families and carers, and staff. To support this, significant
adverse event review reports should be shared with everyone
involved in the event, and a one-page
learning summary completed and published in order to share key
learning points more widely.
- Adverse event reviews are not about
apportioning blame. The aim is to review the care provided to
determine whether there are learning points for the organisation to
improve the service. Organisations then need to implement those
improvements identified to support a greater level of safety for
all people involved in its care systems.
- Leaders should make a clear, public
commitment to staff that the organisation fully supports an open
and fair culture. When things go wrong, staff need to feel able to
be open, that they will be treated fairly and they are supported to
identify the failures in the system and improve delivery.
Please note that sudden, suspicious,
accidental or unexplained deaths must be reported to the Procurator
Fiscal, this includes sudden, unexpected and unexplained perinatal
Further information and guidance is available in the
guide produced by the Crown Office and Procurator Fiscal
The link below provides a list of bereavement
support and advice for families in NHS Ayrshire & Arran if you
think you may have been affected by this issue: