Calls to replace ‘flawed and secretive’ system for investigating NHS negligence claims

Campaigners who want to end the secrecy surrounding medical negligence say health boards should no longer be allowed to investigate themselves.

Bereaved families are demanding the creation of an independent investigatory body with powers to act over medical negligence, misconduct and mistakes.

They want a body similar to the Police Investigations And Review Commission (PIRC) to replace the current Serious Adverse Event Review (SAER) which allows health boards to hold secret investigations.

Former police officer Scott Herd, who lost his daughter Jessica, 26, five years ago, is still fighting for answers over why NHS Fife failed to implement their protocols for treating sepsis.

He said: “Our family have spent years trying to find answers to why Jessica died, and whether the mistakes which cost our daughter’s life have been eradicated so others are saved from harm.

“We found the system so deeply flawed and secretive that we are no nearer to finding the truth than we were when Jessica died.”

Last month The Sunday Post revealed that despite repeated attempts by the Scottish Government to create an open system which upholds the duty of candour to patients and families, health boards are refusing to publish the outcomes of SAER reports.

The NHS across Scotland has paid out more than £330 million in negligence claims over six years.

Scott said: “Health boards are allowed to investigate themselves, and there is no way of ensuring changes are implemented even after they are identified because officials are hiding behind data protection laws.”

Jessica Herd was in her teens when she developed complex regional pain syndrome (CRPS), a disorder that leaves victims in pain with no immediate identifiable cause.

Scott said: “It is a particularly horrible condition, leaving sufferers in agony. Jessica fought bravely despite being plagued by CRPS.”

Jessica Herd with her parents on her graduation day.

Jessica worked with pupils who had difficulties at Bell Baxter secondary school in Cupar.

But after collapsing, she was admitted to Kirkcaldy’s Victoria Infirmary in July 2020. Tests showed Jessica’s heart was racing, but despite that being an early sign of sepsis and toxic shock, medical teams failed to instigate the sepsis treatment protocol that could have saved her life.

Three days later Jessica was transferred to Edinburgh Royal Infirmary, where specialists quickly identified sepsis and “profound septic shock”.

Jessica’s family were stunned to be told she was “brain dead”.

Life support was withdrawn on July 26, and Jessica’s cause of death was noted as multiple organ failure.

Jessica’s family say it is impossible to understand how NHS Fife got things so wrong, beginning with their failure to instigate the Sepsis Six protocol within an hour of the fatal infection being suspected.

They say the SAER left so many unanswered questions that they battled for a Fatal Accident Inquiry (FAI).

Scott said: “The lack of transparency, duty of candour failures, and NHS Fife’s determination to find their catalogue of identified failures were not seen as contributing to Jessica’s death meant the whole SAER process traumatised us even further.

“The SAER was considered by the Crown Office as being the truth of what happened to Jessica. As a result, we were denied an FAI.

“We remain concerned that nothing has been learned from Jessica’s death, and fear other patients remain at risk of the same thing happening to them.

“After our daughter died, we repeatedly asked for a meeting with NHS Fife CEO Carol Potter, but she refused. She even refused to speak with our MSP.”

Tory MSP Stephen Kerr said: “We need an urgent overhaul of how serious incidents in the NHS are investigated.

“That means establishing a genuinely independent body, modelled on PIRC in policing, whose only job is to investigate clinical failings.

“But oversight alone isn’t enough. There must be real protection for whistleblowers. We should make it a legal requirement to report serious wrongdoing, but that must go hand in hand with robust legal safeguards to protect those who come forward.

“If staff are silenced or bullied into compliance, patients suffer – and trust in our health service is eroded.”

NHS Fife said: “We are very limited in our ability to comment publicly on the care of any individual patient for reasons of confidentiality.

“A complaint into Ms Herd’s care was previously escalated to the Scottish Public Services Ombudsman, which reviewed the case and found the care provided was appropriate.

“It also noted that the Significant Adverse Events Review carried out had been thorough.”