We know that NHS Borders already provides excellent care but we also know that sometimes things go wrong. Being involved in an adverse event can be a stressful experience, especially after a very serious event when someone has been seriously injured or has died.

It is important that you are supported following an adverse event and your manager or the Patient Safety Team will have information available for you. This leaflet aims to provide information on what you need to know about the process and where you can access support.

Significant Adverse Events (SAE) can be described as an unexpected or potentially avoidable event that could have resulted, or did result in, unnecessary serious harm or death of a patient, staff member, visitor or member of the public. This includes events which have resulted in a major or extreme adverse outcome as defined within the risk matrix. In addition, this includes NHS Borders unexpected and preventable events or any event deemed by the organisation as being significant.

Significant Adverse Event Reviews (SAER) will be conducted openly and fairly. The purpose of a review is to identify underlying causes or system failures which may have led to an event occurring. NHS Borders is
committed to a “just culture” in creating an environment where learning and accountability are fairly and
constructively balanced. The Board has a non-punitive approach to human error and aims to learn from mistakes and not to apportion blame. If the lead reviewer considers, however, that there are issues about the performance of an individual member of staff, this will be referred to the appropriate line manager and should not be part of the review.

NHS Borders is committed to ensuring that when a SAE occurs the event will be managed effectively to ensure that:

• the patient and their family are safe and supported
• staff members are safe and supported
• the organisation appropriately reviews what happened in an open, fair and thorough way, within defined timelines
• the organisation learns from the event and implements any required improvements

A Lead Reviewer will be appointed to conduct the SAER. This person will be a senior colleague within the
organisation but not, typically, someone who has had direct contact with the patient or staff member. To ensure objectivity, the Lead Reviewer will be a person who does not manage the service, ward or department in which the care or treatment was delivered to a patient or where a staff member works.

The SAER Lead Reviewer acts as chair of any meetings that form part of the review process and is the author of the SAER report. The SAER process is coordinated and supported by the Patient Safety Team or the Health & Safety Team. They ensure that the Lead Reviewer adheres to the NHS Borders Adverse Event Management Policy.

The Lead Reviewer will make the decision about how to carry out the review and which methods will be used. They will need to gather information to understand what has happened and they do this in a number of ways. These may include round-the-table meetings, interviews or requests for statements.
Staff who were involved in the adverse event or who may be able to offer specialist advice in relation to the incident will be asked to be part of the review. These may be internal or external multidisciplinary colleagues.

If staff are asked to attend a meeting or interview, they will be informed, in writing, of the date, time and venue well in advance. Staff can bring someone with them for support (such as a colleague or manager). If this is the case the meeting organiser must be made aware of this beforehand and the person must introduce themselves at the start of the meeting and state their reason for attending. A member of the Patient Safety Team may also be at the meeting to provide support.

All meetings and interviews are recorded and then transcribed.

When asked to become involved in a review, it is expected that:

• staff will fully and actively engage throughout the process
• staff will communicate openly, respectfully and honestly with everyone involved
• staff must operate within all relevant codes of conduct (dependent on the Professional Body they belong to e.g. GMC, NMC, CSP, COT) and implement their professional duty of candour.
• staff must adhere to the Board’s code of confidentiality 
• staff must fully implement any learning or education relevant to their role and sphere of practice
• staff must identify if they need help and support

A report will be compiled by the Lead Reviewer with support from the Patient Safety Team or the Health & Safety Team. This will also be ‘peer reviewed’ by a number of senior colleagues and/or subject matter experts. Peer reviewers may also be external to NHS Borders. The draft version of the report will not usually be shared with staff. Once the report is finalised and approved it will then be available to be shared internally or externally to the organisation. At this point it may also be shared with the person who was harmed or their relatives, carers or representatives.

At this point an improvement plan will be created based on the report recommendations. This will be owned by the service(s) where the adverse event occurred.

The approximate timescale for the entire SAER process is 18 weeks/4 months.

It is important that, in a patient safety event, patients and/or their families or carers are as involved in the SAER process as it may be possible they have a valuable insight into what happened. The SAER Lead Reviewer will make contact with the patient and/or their family, if they are willing to engage, at the start of the review. 

This initial discussion will be for the lead reviewer to:

• introduce themselves and describe their role
• apologise that something has gone wrong
• explain the review process and timescales
• ask if they have any key points, concerns or questions they would like to be taken into account during the course of the review
• agree a method of sharing the outcomes of the review and the report once complete

Patients and/or their relatives are not invited to attend meetings or discussions with staff during the course of the review. The identity of staff will, as much as is possible, remain anonymous, with only their role title being used during discussions with the patient and/or their family or carers and throughout the SAER report.

There is a Significant Adverse Event (SAE) Guidance document available on the NHS Borders intranet that offers more detailed information on the process and the roles of everyone involved.

NHS Borders must also demonstrate that, as an organisation, we are applying the Duty of Candour. Being open when things go wrong is key to the partnership between patients and those who care for them. We have a professional duty to acknowledge when something has gone wrong and provide an honest explanation.

Openness about what happened and discussing adverse events promptly, fully and compassionately can help people cope better with the after-effects of adverse events.

Being open involves:

• acknowledging, apologising and explaining when things go wrong
• if appropriate, conducting a through review into the adverse events which involves patients, relatives, carers and staff, and aims to identify lessons that will support improvements and help prevent the adverse event being repeated and
• providing support for those involved to address any physical and/or psychological consequences of what happened

NHS Borders recognises the impact that a significant adverse event may have on staff and our commitment is that our approach will be:

• fair and through
• compassionate
• transparent and honest
• timely and consistent

Everyone reacts differently to stressful or upsetting situations and emotions of fear, guilt, sadness or anger may develop. It is important that staff talk about their feelings with people they trust. If the SAER centres around a member of staff who has experienced injury or ill health due to an event, that staff
member will be fully supported. All staff are entitled to support throughout the adverse event review process. This can be provided from a line manager or colleague, the Work & Wellbeing Service, the Patient Safety Team, Health & Safety Team, Chaplaincy Services, staff-side (union) organisations and/or any other relevant Topic Specialist Service.

We recognise that healthcare is complex and in some cases, despite our best efforts errors happen and things can go wrong. You should expect the adverse event to bother you – remember your response is temporary and you are having a normal response to an abnormal event. Make a conscious effort to work through it. Also realise that others around you may be under stress too. If others were involved help them too and share your feelings. Talk to friends/colleagues about your experience and participate in any de-brief sessions; this can help reduce feelings of isolation and stress.

There may be times, however, when you will be advised that you are not to discuss the adverse event with your colleagues. This would apply in cases where the Police or Health & Safety Executive are involved or if a patient or their family are pursuing a legal claim against the organisation. It is recognised that this situation may add to any stress you are experiencing.

Do look after yourself, get enough sleep and try to relax. Don’t isolate yourself and seek support from your GP or Occupational Health if you feel additional intervention is required or if you’re not recovering from the event. 

Things to avoid:

• drinking alcohol excessively
• staying away from work unnecessarily
• withdrawing from others and reducing leisure activities
• using legal or illegal substances to numb consequences
• having unrealistic expectations for recovery
• being too hard on yourself

You should seek medical advice if:

• you have trouble sleeping for more than a week
• your response to the event is too intense or lasting too long
  you are experiencing physical symptoms to reminders of the event (for example: racing heart, nausea, sweating)
• you are experiencing symptoms associated with depression or suicidal feelings
• you are unable to return to work
• your response to the event is impacting on your private life and your ability to cope generally with normal activities

Occupational Health Services

NHS Borders Intranet Microsite: Occupational Health | Work & Wellbeing
Staff Counselling
NHS Borders Confidential Contacts
Self-Help Resources
Tel: 01896 825982

Spiritual Care/ Chaplaincy Services
Community Listening Service | a confidential ‘sympathetic ear’ for patient’s & staff
Tel: 01896 826564

Patient Safety Team
Borders General Hospital
Email: patient.safety@borders.scot.nhs.uk 
Tel: 01896 826719

Health & Safety Team
Borders General Hospital
Tel: 01896 82825

References & Further Information

• Adverse Event Management Policy | 2020
• Significant Adverse Event Guidance | 2020
• Risk Matrix – Impact & Consequence Definitions
• Scottish Government “Organisational Duty of Candour guidance” | March 2015
• Nursing and Midwifery Council (NMC) and General Medical Council (GMC) “Openness and honesty when things go wrong: the professional duty of candour” June 2015
• Healthcare Improvement Scotland (HIS)