Patient Safety Commissioner for Scotland Bill

Author: Kathleen Robson

PDF Published: Thursday 26 Jan 2023 (SB 23-04)

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Overview
Report

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Overview
Report
- Summary
- Introduction
- The Independent Medicines and Medical Devices Safety Review
- Patient safety
  - Significant adverse events
  - Clinical Negligence and Other Risks Indemnity Scheme
  - Complaints
- Current systems for monitoring and ensuring patient safety
  - Medicines and medical devices
  - Patient care
- What is a commissioner?
- The Bill's provisions
  - Functions
  - Principles and communication
  - Strategic planning
  - Advisory group
  - Investigations
  - Information gathering
  - Investigation report
  - Defamation
  - Other provisions
- Financial Memorandum
- Summary of written evidence
  - Roles and responsibilities
  - Powers
  - Appointment process and funding
  - Suggested changes or alternatives
Sources

The bar graph shows the most common types of significant adverse event reported between January 2020 and October 2021. This shows there were 207 unexpected deaths, 188 suicide, 184 treatment problems, 85 diagnostic problems and 54 falls.

Image: Figure 1: Most common type of significant adverse event, January 2020 to October 2021

The bar graph shows the most frequent specialties or areas of healthcare in which significant adverse events occurred between January 2021 and October 2022. This shows that 264 took place in a mental health setting, 70 were in maternity/obstetrics, 68 in surgical, 60 in accident and emergency and 56 during patient transfer.

Image: Figure 2: Most common specialities in which significant adverse events occurred January 2020 to October 2021

Scottish Parliament. (2022, October 6). Patient Safety Commissioner for Scotland Bill as introduced. Retrieved from https://www.parliament.scot/-/media/files/legislation/bills/s6-bills/patient-safety-commissioner-for-scotland-bill/introduced/bill-as-introduced.pdf [accessed 25 January 2023]

The Independent Medicines and Medical Devices Safety Review. (2018). Terms of Reference. Retrieved from https://www.immdsreview.org.uk/terms-of-reference.html [accessed 10 January 2023]

Independent Medicines and Medical Devices Safety Review. (2020, July). First Do No Harm. Retrieved from https://www.immdsreview.org.uk/downloads/IMMDSReview_Web.pdf [accessed 1 December 2022]

The Independent Medicines and Medical Devices Safety Review. (2020, July 8). Press conference speech 8 July 2020. Retrieved from https://www.immdsreview.org.uk/downloads/IMMDSReview_Baroness_Cumberlege_speech.pdf [accessed 1 December 2022]

Scottish Government. (2020, September 1). Protecting Scotland, Renewing Scotland: The Government's Programme for Scotland 2020-21. Retrieved from https://www.gov.scot/publications/protecting-scotland-renewing-scotland-governments-programme-scotland-2020-2021/ [accessed 1 December 2022]

Scottish Government. (2021, March 5). Consultation on a Patient Safety Commissioner Role for Scotland. Retrieved from https://consult.gov.scot/healthcare-quality-and-improvement/patient-safety-commissioner-role-for-scotland/ [accessed 1 December 2022]

Flott, K., Fontana, G., & Darzi, A. (2019). The Global State of Patient Safety. Retrieved from https://www.imperial.ac.uk/media/imperial-college/institute-of-global-health-innovation/GlobalStateofPS_DIGITAL_16Sep19%5B2%5D.pdf [accessed 20 January 2023]

Slawomirski, L., & Klazinga, N. (2022, August 12). The economics of patient safety: From analysis to action. Retrieved from https://www.oecd-ilibrary.org/docserver/761f2da8-en.pdf?expires=1674219464&id=id&accname=guest&checksum=4CAA45C8118F017F1666EF8AB70F28DD [accessed 20 January 2023]

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World Health Organisation. (2019, September 13). Patient Safety. Retrieved from https://www.who.int/news-room/fact-sheets/detail/patient-safety [accessed 20 January 2023]

Vincent, C., Neale, G., & Woloshynowych, M. (2001). Adverse events in British hospitals. BMJ Open, 322, 517-519.

Healthcare Improvement Scotland. (2019, December). Learning for adverse events through reporting and review - A national framework for Scotland. Retrieved from https://www.healthcareimprovementscotland.org/our_work/governance_and_assurance/learning_from_adverse_events/national_framework.aspx [accessed 19 2023]

Healthcare Improvement Scotland. (2022, January 12). Adverse Events Notification System: Update Report. Retrieved from https://www.healthcareimprovementscotland.org/our_work/governance_and_assurance/learning_from_adverse_events/aens_report_2022.aspx [accessed 19 January 2023]

Central Legal Office. (2022, March). Clinical Negligence and Other Risks Indemnity Scheme (CNORIS) Annual Report 2020-21. Retrieved from https://clo.scot.nhs.uk/media/23888/cnoris_annual_report_2020-2021.docx [accessed 16 January 2023]

Public Health Scotland. (2022, December 13). Annual Report on Complaints - 2021 to 2022. Retrieved from https://publichealthscotland.scot/publications/annual-report-on-complaints/annual-report-on-nhs-complaints-2021-to-2022/ [accessed 16 January 2023]

Scottish Public Services Ombudsman. (2022, May 24). Complaints determined by authority and outcome. Retrieved from https://www.spso.org.uk/sites/spso/files/communications_material/statistics/2021-22/AnnualStatisticsComplaintsDeterminedbyAuthorityandOutcome2021-22.pdf [accessed 25 January 2023]

Scally, G., & Donaldson, L.J. (1998). Clinical governance and the drive for quality improvement in the new NHS in England. British Medical Journal, 317(7150), 61-65.

Scottish Public Services Ombudsman. (2016). The NHS Scotland Model Complaints Handling Procedure. Retrieved from https://www.msg.scot.nhs.uk/wp-content/uploads/Circulars/DL%27s/NHS%20Model%20Complaints%20Handling%20Procedure%20-%203%20October%202016.pdf [accessed 19 January 2023]

Organisation for Economic Cooperation and Development. (2016, February 12). OECD Review of Healthcare Quality: United Kigndom 2016. Retrieved from https://www.oecd.org/unitedkingdom/oecd-reviews-of-health-care-quality-united-kingdom-2016-9789264239487-en.htm [accessed 2 December 2022]

Scottish Parliament. (2022, October 6). Patient Safety Commissioner for Scotland Bill - Policy Memorandum. Retrieved from https://www.parliament.scot/-/media/files/legislation/bills/s6-bills/patient-safety-commissioner-for-scotland-bill/introduced/policy-memorandum-accessible.pdf [accessed 26 January 2023]

Scottish Parliament. (2022, October 6). Patient Safety Commissioner for Scotland Bill - Financial Memorandum. Retrieved from https://www.parliament.scot/-/media/files/legislation/bills/s6-bills/patient-safety-commissioner-for-scotland-bill/introduced/financial-memorandum-accessible.pdf [accessed 26 October 2023]

Cabinet Office. (2022, July 12). HM Government Public Appointments - Patient Safety Commissioner. Retrieved from https://publicappointments.cabinetoffice.gov.uk/appointment/patient-safety-commissioner/ [accessed 25 January 2023]

Scottish Public Services Ombudsman. (2022). SPSO annual report and accounts 2021-22. Retrieved from https://www.spso.org.uk/annual-report/2021-22.html [accessed 26 January 2023]

Scottish Information Commissioner. (2022). Annual Report and Accounts 2021-22. Retrieved from https://www.itspublicknowledge.info/annual-reports [accessed 26 January 2023]

Ethical Standards Commission. (2022). Annual Report and Accounts 2021-22. Retrieved from https://www.ethicalstandards.org.uk/sites/default/files/publications/ESC%20Annual%20Report%20and%20Accounts%202020-21%20APPROVED.pdf [accessed 26 January 2023]

Children and Young People's Commissioner Scotland. (2021). Annual Report and Accounts 2020-21. Retrieved from https://www.cypcs.org.uk/wpcypcs/wp-content/uploads/2021/11/Accounts_20-21_CYPCS.pdf [accessed 26 January 2023]

Scottish Human Rights Commission. (2022). Annual Report and Accounts 2021-22. Retrieved from https://www.scottishhumanrights.com/media/2394/accounts_21-22_shrc-final-signed.pdf [accessed 26 January 2023]

Scottish Biometrics Commission. (2022). Annual Report and Accounts 2021-22. Retrieved from https://www.scottishhumanrights.com/media/2394/accounts_21-22_shrc-final-signed.pdf [accessed 26 January 2023]

Standards Commission for Scotland. (2022). Annual Report and Accounts 2021-22. Retrieved from https://www.standardscommissionscotland.org.uk/uploads/files/1661502066220725SIGNEDStandards_Commission_for_Scotland_Annual_Report_and_Accounts.pdf [accessed 26 January 2023]

Scottish Parliament. (2023). Scottish Public Services Ombudsman written submission to the Health, Social Care and Sport Committee on the Patient Safety Commissioner for Scotland Bill. Retrieved from https://yourviews.parliament.scot/health/patient-safety-commissioner-for-scotland-bill/consultation/view_respondent?uuId=613547420 [accessed 12 January 2023]

Last Updated: 7/7 6:31pm

Image: Figure 1: Most common type of significant adverse event, January 2020 to October 2021

Image: Figure 2: Most common specialities in which significant adverse events occurred January 2020 to October 2021

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