Decade of missed opportunities blamed on ‘avoidable deaths’

A father whose son was stillborn in hospital said the health board had years of “missed opportunities” to address problems in the areas which “failed” his son.

Fraser Morton’s son Lucas died at Crosshouse Hospital near Kilmarnock in November 2015 and NHS Ayrshire and Arran subsequently apologised for his “unnecessary” death and identified failings by hospital staff.

His death was one of six “avoidable deaths” in eight years at the hospital, which led Health Secretary Shona Robison to last year instruct watchdog Healthcare Improvement Scotland (HIS) to review the management of “adverse events” – including the deaths – at the health board.

Giving evidence to Holyrood’s Health and Sport Committee, Mr Morton, from Kilmarnock, said: “I was shocked to see the same failings in care in 2006 in terms of staffing, training, handover, communication – these were the same areas that failed Lucas in 2015.”

He said: “The evening our son died we were told initially the staffing levels were short by 30 per cent in the maternity unit.”

He said following the HIS review in 2016 the maternity unit now has 20 additional staff, including 17 midwives.

Mr Morton said in an internal review following red flags regarding adverse events in 2013, the health board “looked at everyone but themselves… and I believe that was an opportunity missed”.

The need for extra staff “could have and should have been identified earlier”, he said, had adverse events been monitored “properly” and a better investigation carried out into the red-flagged figures. Mr Morton added

that the Crown Office was not informed of his son’s death and when he complained to the health board he was told “Why don’t you just sue us?”.

He said he did not believe health boards were accountable and called for a national standard for an “adverse event”.

Mr Morton now believes a “corner has been turned” at the health board, which is taking action beyond the recommendations in the review.

The committee also heard from Ella Brown, whose father, who had Alzheimer’s disease, died following a fall in Victoria Hospital, Kirkcaldy in 2012.

She said: “I could see the ward was totally understaffed. I told the nurses, ‘watch him, he’ll wander’. The next night he got up went to the toilet, fell and fractured his skull and he died.” She has since worked with the NHS board to instigate changes aimed at reducing hospital falls.