Over 1000 'adverse events' in women and infants' care

The true figure will be higher as two health boards - Grampian and Orkney - have yet to respond to the freedom of information request, and a number of health boards reported the totals per year as "less than five" to protect patient confidentiality.

In those instances, they have been counted as one, but the number could be up to four.

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Saers are internal health board investigations which are carried out following events that could have, or did, result in major harm or death for a patient.

Major harm is generally classified as long-term disability or where medical intervention was required to save the patient's life.

They are intended as learning exercises to establish what went wrong and whether it could have been avoided. Not all Saers find fault with the patient's care, but the objective is to improve safety.

Scotland's largest health boards - NHS Greater Glasgow and Clyde and NHS Lothian - recorded the highest number of Saers, with 388 and 257 respectively.

NHS Lanarkshire was only able to provide data from April 2015 onwards, but this revealed a total of 194 Saers - of which 102 related to neonatal or maternity services, and 80 for obstetrics.

A Fatal Accident Inquiry involving NHS Lanarkshire has already been ordered into the deaths of three infants - Leo Lamont and Ellie McCormick in 2019, and Mirabelle Bosch in 2021 - because they had died in "circumstances giving rise to serious public concern".

The Crown Office said it wished to "establish whether there is learning that could minimise the risk of future death in similar circumstances".

The FAI is expected to take place in May next year. 

Separate figures obtained under FOI also show that three negligence claims were lodged against NHS Lanarkshire in relation to neonatal care over the past decade - two in 2015/16 and one in 2017/18.

Judith Park, director of acute services at NHS Lanarkshire, said:  “Significant Adverse Events Reports identify cases where there may have been areas of treatment or care that fell short of the high standards we strive to offer each and every one of our patients.

“Saers provide us with the opportunity to put in place actions and learning that will ensure any failings are addressed.”

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For Scotland as a whole there is nothing to indicate that the number of Saers being carried out into adverse events in obstetrics, maternity, gynaecology or neonatal services has increased over the past decade.

In most regions, the numbers have fluctuated from year to year with no obvious trend up or down.

However, NHS Fife appears to have seen a spike since the beginning of the pandemic.

Between April 2020 and November this year, it initiated 31 Saers in total in contrast to fewer than five per year from 2012/13 to 2017/18.

In a statement NHS Fife said this uptick had coincided with the implementation of new national guidance on the Significant Adverse Event Review process in January 2020, adding: "While the number of Saers carried out has increased, the number of adverse events remained broadly consistent throughout the stated period.”

NHS Tayside said it was unable to provide any data prior to January 1 2020, but since then has initiated at least three Saers in maternity and neonatal services. 

Data also shows that NHS Greater Glasgow and Clyde has faced more negligence claims over the past decade in relation to obstetrics, maternity, gynaecology or neonatal services than any other health board.

Figures obtained under FOI show that a total of 425 claims were lodged between April 2012 and November this year - 204 of them in a single two-year period from 2013/14 to 2014/15.

As Scotland's largest health board, NHS GGC provides services to a core population of 1.2million and specialist regional services to more than half the country's population.

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However, the number of negligence claims was nearly three times that of the second largest board, NHS Lothian, which faced around 160 claims.

Not all negligence claims will be upheld, but where they are health boards are liable to pay the first £25,000 of any settlement.

The remainder is funded from Scotland's national Clinical Negligence and Other Risks Indemnity Scheme (CNORIS), a mandatory system into which all health boards pay.  

Excluding Grampian and Orkney - which have not yet responded to FOI requests - there have been at least 1,026 negligence claims across NHS Scotland since 2012 in relation to obstetrics, maternity, gynaecology or neonatal services.

In a statement, NHS GGC said: “Due to patient confidentiality , we are unable to comment on individual cases.

"In some instances the time between incidents taking place and claims being submitted can be substantial which may impact how the figures are reported.

"At all times, NHSGGC staff strive to carry out their duties to the highest professional standards in line with national clinical guidelines.”