Review of adverse events - Ayrshire Maternity Unit, University Hospital Crosshouse, NHS Ayrshire & Arran

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.

If you are a member of the public and would like to share your experiences of the Ayrshire Maternity Unit please send us an email with your name and contact details to hcis.aa-review@nhs.net

We would be grateful if you could contact us by Friday 31 March in order for the review team to take account of your comments.

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 death. Further information and guidance is available in the guide produced by the Crown Office and Procurator Fiscal Service.

Bereavement support

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: