On 15 September 2021 the Scottish Government published “Maternity and neonatal (perinatal) adverse event review process: guidance” as an operational guidance supplement to the Healthcare Improvement Scotland (HIS) 2019 “Learning From Adverse Event Review National Framework for Scotland“. The new guidance was developed in recognition that maternity and neonatal (perinatal) reviews have additional requirements to achieve delivery of the national HIS framework, such as compliance with Perinatal Mortality Review Tool guidance and timelines. Watch the (2021) MCQIC Perinatal Mortality Review Tool webinar here. Dr Corinne Love and Dr Edile Murdoch launch the new Perinatal guidance at 46:40 in the video.
Supporting the New Perinatal Guidance
In December 2021, the Scottish Government commissioned the SPN to support the perinatal community to implement the new guidance in five ways (detailed in SG perinatal SAER guidance section 4.c.6 Capturing and sharing learning from adverse events):
As work on these 5 SPN outcomes progressed, it became increasingly clear that collaboration alone would not result in national consistency. The parallel workstreams being delivered by multiple strategic partners also required national scoping and co-ordination, including:
Adverse Events Framework Revision
Work began in October 2022 to revise the current national AE framework. 14 Focus groups took place during Summer 2023 and the outputs can help inform the review of the Maternity and neonatal (perinatal) adverse event review guidance alongside the SPN scoping work. The overarching framework revision focuses on these key areas.
This work continues to develop via the adverse events network which meets every 2 months. It is anticipated that the Maternity and Neonatal (perinatal) adverse event review guidance will be an additional supplement to the revised AE framework. Timescales for delivery are uncertain due to organisational re-structure within the Quality Assurance and Regulation Directorate at HIS. However, the work has a commitment from all NHS boards to collaborate towards a national approach and will be prioritised. Laura Brown has been invited to sit on the adverse events network to support communication flow and collaboration.
Healthcare Improvement Scotland (HIS) Learning systems – Adverse Events Community of Practice (CoP)
A new SharePoint Adverse Events (AE) CoP, hosted on MS Teams, piloted in May 2022. It includes a collaborative AE toolkit, hosts meeting and event documentation, and an NHS board discussion space where risk and governance leads can ask questions and share ideas and knowledge about their local processes and experiences.
On 30 November 2023 the national AE learning platform will be launched as the central hub for the site. Each NHS board will have ownership of its own area of the site. Learning summaries will be uploaded to encourage national learning alongside other information which may be of interest to other boards.
Work of the Scottish Fatalities Investigation Unit (SFIU) (where HIS complete a learning summary at their request for specific cases where a discretionary FAI is being considered) will also be shared on this site. Learning sessions and case discussions groups/webinars are also planned with the AE network and beyond.
Work is underway with other organisations, such as COSLA (National Suicide review process) and SPN, wishing to have workspace on the new site. This site is available to staff with an NHS e-mail address with membership access agreed by the AE team at HIS
NHS Education for Scotland (NES) – Education and Training
In response to perinatal guidance section: 4.b.5 Supporting staff training and wellbeing, NES provides resources for NHS staff involved in adverse event reviews and those in leadership/management positions. They include learning from safety incidents in complex care environments and building a safety culture and other associated areas. Find details on the Patient Safety Zone on TURAS Learn. NES also provides:
In addition to training, appropriate measures must be in place to support the wellbeing of staff during and following involvement in an adverse event review process. It is possible this support could be provided through future collaboration with NES and/or EC4H