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NHS Grampian admits nine patient deaths were probed after care ‘mistakes’

NHS Grampian candour

Health chiefs in the north-east investigated mistakes made in the care of nine hospital patients who died last year, it can be revealed.

The figure for 2019/20 represented a significant rise on the five fatalities which were linked to “adverse events” at NHS Grampian facilities in the year before.

Only NHS Greater Glasgow and Clyde recorded more deaths which triggered the “duty of candour” process in Scotland, with 13.

NHS Lanarkshire and NHS Dumfries and Galloway also had nine cases where patients did not recover, while there were six at NHS Ayrshire and Arran and NHS Forth Valley, two at NHS Highland and fewer than five at NHS Fife, NHS Lothian and NHS Borders.

NHS Grampian candour
Aberdeen Royal Infirmary

Under a 2018 law, boards are required to demonstrate that they have learned lessons from an incident that has resulted in the harm or death of a patient, as well as offering an apology to the families involved and publishing a report each year.

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

The legislation hit the headlines last week when it was alleged at first minister’s questions in Holyrood that a family had not been told the death of their child was linked to the water supply at a Glasgow hospital.

Every NHS board produces a report each year detailing the number of cases which triggered the duty of candour each year.

We revealed in December that NHS Grampian had recorded 87 incidents which met the threshold in 2019/20, more than any other health authority in Scotland, and up from 60 in the year before.

After Grampian, the NHS board with the next-highest number of incidents last year was Ayrshire and Arran, with 73, followed by Greater Glasgow and Clyde, with 49, and Dumfries and Galloway, with 34.

NHS Grampian candour

NHS Tayside reported 30, double the 15 it had recorded in the previous year, while there was a rise from 16 to 23 at NHS Highland last year.

Elsewhere, there were 28 of the probes at Fife, 23 at Lothian, 20 in Lanarkshire, 15 at Borders, six at Forth Valley, two in Orkney, and one each at Shetland and Western Isles.

Unlike every other health board in Scotland, NHS Grampian and NHS Tayside do not publish the number of duty of candour cases which involved a death.

However, NHS Grampian has now released its figure following our freedom of information request. NHS Tayside is still to respond.

Liam Kerr MSP

Liam Kerr, Scottish Conservative MSP for the north-east, said: “The NHS can’t avoid every accident that happens.

“But basic transparency would at least help prevent the very worst mistakes from being repeated.

“There should be a national effort to collate this data, so health boards can learn from each other.

“If that helped save one life across Scotland, it would be an invaluable exercise.”

In each case we investigate the circumstances and aim to learn to ensure any mistakes are not repeated.”

A spokesman for NHS Grampian said: “The variation in rates across Scotland demonstrates that this process does involve judgement and comparisons or deeper interpretation is complicated.

“On occasions where our care does not meet with the high standards we aspire to, we communicate openly with patients and their families and offer our sincere apologies.

“In each case we investigate the circumstances and aim to learn to ensure any mistakes are not repeated.”