Baby death families hear review findings
A report into the deaths of babies at an Ayrshire maternity hospital has made a number of recommendations for the handling of significant adverse events.
Health Secretary Shona Robison ordered the review into six "unnecessary" deaths of babies at Crosshouse Hospital after a BBC investigation in November.
The review team met with families in Kilmarnock to outline the key findings.
Campaigners want a public inquiry into the deaths and a new independent regulator for maternity units.
Healthcare Improvement Scotland (HIS) said that the final report would not be published for another two weeks.
The families were told about a number of recommendations for NHS Ayrshire and Arran - including better engagement with families.
They were also told that the final report is to include national recommendations for better training in maternity services.
The findings could have ramifications for health boards across the country.
Elaine Pringle's daughter Rebecca was born at Crosshouse hospital five years ago. She has cerebral palsy and is unable to walk or talk.
She told the BBC she was sorely disappointed in the review's key findings, which she said only addressed how the health board handled significant adverse events.
These are mistakes with major consequences such as an unexpected harm or death.
Ms Pringle said: "We need to have a public inquiry and an independent report looking into what happened - not an HIS review."
Several of the families and campaign group ASAP-NHS have called for a public inquiry and a new body to independently investigate such cases and look at whether they need to be prosecuted.
Campaigner Roger Livermore, a former NHS inspector and prosecutor, said the report did not address concerns about the safety levels for mothers and babies at the unit.
He said: "What is required is immediate action by the government to implement the law which would ensure effective precautions to prevent harm.
"It requires an independent regulator to be created to make sure standards are achieved."
Earlier this year, BBC Scotland found that a number of boards were failing to consistently record or learn lessons from the most serious adverse events in maternity units and hospitals - despite national guidelines from HIS stating that they should.
It is not the first time adverse events at Ayrshire and Arran have been investigated by HIS.
In 2012, the then health secretary Nicola Sturgeon called for HIS to investigate claims that Ayrshire and Arran Health Board was failing to properly investigate, record or learn from adverse events.
The following year their follow-up report into the board found great progress to much praise.
Mr Livermore said a number of the key findings - including inconsistent reporting and the need to engage with families - were the same in the latest review as they were in 2012.
"It is in effect a repeat of what happened five years ago," he said.
"They're looking for improved engagement with families and better training for staff in terms of using the system together with better training in general."
Scotland's chief medical officer Catherine Calderwood said: "We haven't yet seen the report, but when we do see it we will take the findings extremely seriously.
"The reason the cabinet secretary commissioned this report was that we wanted to to assure ourselves that serious adverse incidents in Ayrshire and Arran are taken seriously, that they are investigated properly and that findings are acted on."
NHS Ayrshire and Arran said it recognised how difficult it must be for the families involved in the review "to revisit painful and distressing memories".
Chief executive John Burns said: "NHS Ayrshire & Aran has fully cooperated with HIS during their review of systems and processes within our maternity services and, once the report is published, we will publish our improvement plan/learning note based on the published recommendations.
"NHS Ayrshire & Arran recognises the importance of engaging with families and we regret if families did not feel that they received the information or support they would have expected from us.
"Part of the review conducted by HIS invited families to make contact if they wished to share their experiences. Five of the families that came forward indicated that they would want to meet with the board and we have made contact with those families."
The health board said it was committed to "continuous improvement" and had invested in maternity staffing.
Fraser Morton's son Lucas died at Crosshouse Hospital in November 2015 following a series of errors by hospital staff.
NHS Ayrshire and Arran gave the family an "unreserved apology" and admitted Lucas's death was "unnecessary".
Speaking after hearing the key findings of the review, Mr Morton told BBC Scotland: "I'm still no clearer on the circumstances that resulted in my son's unnecessary death.
"I'm no clearer on the accountability within NHS Ayrshire and Arran that created those circumstances and I don't know how the recommendations going forward are going to be implemented when they have failed to implement them from 2012."
He added: "What I would like to happen now is measures being put in place to prevent what happened to Lucas ever occurring again."
A HIS spokesman cautioned against speculating on the final report's findings until the report was published in its entirety.
He said: "As a crucial part of this review and to fully inform our work, we have engaged with families affected and have begun to feed back key findings to them.
"This an important part of the process as we finalise the report, which will be published in the near future."
The review itself has not been without controversy.
In March, the BBC revealed that five of the original six families would be excluded from the official part of the review.
HIS said this was because it would only look at cases since December 2013 - when HIS wrote its previous report on Ayrshire and Arran.
It gave an open invitation to all the families who wanted to share their experience of the hospital but said those affected pre-2013 would not be part of the "formal" process.