Three deaths following mistakes at NHS Tayside hospitals

Three patients died last year following mistakes made by NHS Tayside hospital staff, it has emerged.

The health board revealed the errors under “duty of candour” laws designed to ensure serious unexpected or unintended incidents are investigated properly.

The tragedies were among 14 incidents which triggered the process in the region.

In seven cases, the patient’s treatment had to be “increased” as a result of a blunder.

In one case the patient’s life expectancy was “shortened”, and in another it resulted in “changes to the structure of the person’s body”.

A report produced by NHS Tayside suggests one case involved a person’s health having been harmed as a result of a swab going missing in a surgical theatre.

The errors can be revealed as a result of a 2018 law that requires health boards to show that they have apologised to those involved and learned lessons from any major incident that has resulted in the harm or death of a patient.

Known as “duty of candour”, the regulations were brought in to improve transparency following controversies over attempts by some NHS boards to hide their failings.

How many incidents were there?

NHS Tayside’s report for 2021-22 outlines that there were a total of 18,711 “adverse events or near miss records” reported.

Of these, 17,625 were recorded as adverse events and 1,086 as near misses.

After an evaluation, 14 of them were considered to be adverse events that met the criteria for activating the “duty of candour” procedure.

Local Labour MSP Michael Marra said: “As we watch the NHS struggling through the winter, battered by incompetent government and filled with exhausted and undervalued staff it is more important than ever that we avoid complacency.

“The improved performance on last year’s ‘duty of candour’ report is good news but three deaths is three too many.

‘Breaking point’

“These reports show the dangers of an NHS being run at breaking point.”

The NHS Tayside report outlines some of the lessons that have been learned in the wake of last year’s incidents.

Several examples relate to the management of swabs in theatre areas, while another involves the management of diabetic patients and hypoglycaemic episodes.

NHS Tayside said it could not provide further information on the cases involved, due to patient confidentiality.

All healthcare professionals have a professional responsibility to be honest with patients when things go wrong.”

– NHS Tayside.

Its report said: “NHS Tayside recognises that when adverse events occur during the provision of treatment or care, openness and transparency is fundamental.

“The duty of candour arrangements which have been implemented reflect the Scottish Government’s commitment to place people at the heart of health and social care services in Scotland.

“When harm occurs the focus must be on personal contact with those affected; support and a process of review and action that is meaningful and informed by the principles of learning and continuous improvement.”

It added: “All healthcare professionals have a professional responsibility to be honest with patients when things go wrong.”

The three deaths probed last year reflects a reduction compared with six fatalities reported by NHS Tayside in 2020-21.