Patient killed in oxygen explosion as a second dies in broken lift: Damning dossier reveals NHS failings that caused death
First study shows 345 serious incidents in Scotland including 100 deathsPneumonia patient died after being left for nine days without medicationShocking report reveals another patient had wrong organs stapled together
15:19 GMT, 26 November 2012
A horrifying catalogue of serious errors at NHS hospitals in Scotland has come to light, following a Freedom of Information request.
They include a report from NHS Lothian where a patient on oxygen therapy died in an explosion after lighting a cigarette in a hospital toilet.
In another shocking case, NHS Ayrshire and Arran revealed a patient died after they were stuck in a lift while being transferred to intensive care. The oxygen supply they were receiving and suction equipment ran out during the time they were trapped.
Warning: Two patients using oxygen died after they got too close to a heat source
Another report from the same Trust revealed a patient with pneumonia who died didn't receive medication for nine days after they were admitted because the pharmacy failed to deliver the drugs.
These examples made up a handful of the 345 NHS reports from last year, that were only released following an FOI request from BBC Scotland.
Reasons for deaths or illness included receiving the wrong doses of medication or
emergency treatment not being available.
More than 100 deaths resulted from the incidents reported by Scottish hospitals. However, the number is likely to be far higher as only seven of the 19 boards supplied the number of adverse incidents they had recorded over the past year in response to the FOI request.
Despite this, it is the first time a clearer picture for the whole of Scotland has emerged, because unlike England and Wales, there is no national system for reporting serious incidents.
The documents show variations between health boards in the number of incidents that are reported and what types of investigations are conducted.
Differences in what each board considers to be 'serious' are also apparent, with incident reports ranging from a nurse being injured while hanging Christmas decorations to a baby dying during labour and a surgeon removing a patient's healthy organ.
Work overload: A number of serious incidents revealed NHS staff who had not received adequate training
Scotland's largest health board, NHS Greater Glasgow and Clyde, reported 95 incidents last year despite serving the largest population compared to NHS Shetland, which noted 138.
The study also highlights that all of NHS Tayside's reports list 'nearly identical' learning points.
The BBC investigation also found that the NHS has paid out over 120 million in compensation and legal expenses over the last three years in Scotland.
In two individual cases, NHS Lanarkshire paid out a total of over 6 million.
Jim Martin, the Scottish Public Services Ombudsman, has called for a national system for reporting serious incidents.
A CATALOGUE OF FAILURES
AYRSHIRE & ARRAN
Patient died after an oxygen mask they were wearing got too close after a heat source and exploded.
Inexperienced nurse incorrectly administered medication which caused the death of the patient.
Patient died after treatment ran out while they were stuck in a lift on transfer to intensive care.
BORDERS, DUMFRIES & GALLOWAY
Stillborn baby allocated a community number by a midwife so was recorded as being alive. Family distressed after receiving a birthday card through a public health initiative.
Patient on oxygen therapy died in explosion after lighting a cigarette in the toilet.
Surgeon stapled the wrong organs together during elective surgery.
A pad used during a surgical procedure was unaccounted for and staff couldn't locate it using X-ray.
He said: 'I think one of the things that your (the BBC's) inquiries have highlighted is that across Scotland just now we're pretty confused about what we call things, what things mean and whether for example a critical incident review is a health and safety review, whether it's a review of something that's gone wrong surgically or in a GP's surgery or in a dental surgery.
'It's a confusing picture. I think if we had a simple national system it would be far easier to ask a simple question of the health service and get a clear statistical answer.'
The Scottish Government said it has asked for an urgent review of incident reporting from Health Improvement Scotland (HIS), the body set up to support NHS Scotland and other healthcare providers deliver high quality and safe services.
BBC Scotland said that, in the programme, Robbie Pearson, director of Scrutiny and Assurance at HIS, admits they have no idea of the national picture, and that the officials will be visiting each health board from now until the end of next year.
A total of 22 complaints are made against the NHS every day and the numbers being upheld by the Public Services Ombudsman have increased.
Mr Martin said: 'Last year we upheld something like 56 per cent of the complaints, which is a very worrying number particularly given that the year before the number was only 43 per cent.
'There seems to be an increase in the number of complaints not being resolved satisfactorily in health boards.
'Where I'm worried is that if the trend continues, it will dilute the confidence of the population.
'I can only assume that if we get the learning better, then that will save lives.
'At the moment, the bureaucracy seems from the outside to be the most important thing. In my view the learning should be the most important thing.'
A Scottish Government spokeswoman said a national framework for the management of adverse events is being put in place.
'Scotland is the first country in the world to implement a national patient safety programme across the whole healthcare system and has some of the safest hospitals in the world,' she said.
'We need to support a culture of openness, trust and quality improvement so that we can make sure that lessons are learned from these events.'
Earlier this year, the health secretary ordered an investigation in NHS Ayrshire and Arran after the health board withheld more than 50 reports on serious incidents at its hospitals and clinics.
The BBC revealed that some of that Trust's reports were so heavily redacted (blacking out sections) that they were almost incomprehensible.
BBC Scotland Investigates: How Safe Is Your Hospital airs on BBC One Scotland at 10.35pm tonight