The Scottish Public Services Ombudsman has today published a report calling on NHS Lothian to urgently review their Significant Adverse Event Review (SAER) procedures.

The recommendation arose following a complaint from the family of a patient who died from a staphylococcus aureus bacterium (SAB) infection, a type of bloodstream infection, at the Royal Infirmary of Edinburgh.

The investigation found that the health board should have carried out a SAER following the patient's death. The Ombudsman said that the circumstances of the case met both national criteria and the Board's own criteria for a SAER. Despite this, no SAER was undertaken.

Instead, the Board commissioned a local review which was insufficient and completed by a member of staff without the relevant expertise. As a result, an important opportunity to fully examine the circumstances of the patient's death, identify learning and address potential systemic issues was missed.

This is the latest in a number of reports by the Ombudsman that has found substantive issues in the way SAERs are carried out across health boards in Scotland.

The investigation also found that the nursing care failed to meet the relevant standards for cannula care. This is significant given the SAB infection is presumed to have arisen from an infected cannula site in the patient’s forearm. 

The report is highly critical of the Board's failure to recognise the systemic nature of these failings. Similar shortcomings in nursing care have been identified in previous Ombudsman investigations into NHS Lothian, yet the Board did not acknowledge this case as part of a wider pattern of concern.  

The Ombudsman has recommended that that the board carry out audits of cannula care, record keeping and treatment of SABs in addition to reviews of staff training needs and their SAER procedures. 

Paul McFadden, Scottish Public Services Ombudsman, said;

“SAERs play a fundamental part in ensuring patient safety. They not only identify areas for improvement within the healthcare system but provide important answers to patients and their families around their care.

I have asked Lothian NHS Board to review their SAER procedures to ensure they are complying with the current Healthcare Improvement Scotland framework as a matter of urgency and will follow up on those recommendations.”