Damning reports reveal how patients have needlessly died in Ayrshire’s hospitals.
And health chiefs who withheld vital learning dossiers about the incidents are facing tough new questions.
A string of shocking cases on wards within Ayrshire and Arran have been laid bare.
They include a patient who was trapped in a lift and later died because a life saving oxygen supply ran out.
Another two patients had x-rays which showed cancerous tumours that were not acted upon by medics.
And one patient was admitted to hospital with pneumonia and left without essential medication for nine whole days before dying.
Under-fire bosses have been forced to defend claims they’ve learned little from a catalogue of critical incidents.
Any adverse event in a hospital is supposed to be documented and the findings are then circulated to the relevant staff so that mistakes can be learned from.
But earlier this year, former Ailsa Hospital nurse Rab Wilson proved that NHS Ayrshire and Arran had withheld a large number of those reports.
And on Monday night, a BBC television investigation turned the spotlight on bosses at the underfire health board.
Among a stream of cases to be uncovered is that of two separate patients who fell from their hospital beds and later died.
And in another case, an inexperienced nurse wrongly administered medicine which led to the death of a patient.
However, Ayrshire and Arran bosses insist they are making sure mistakes don’t repeat themselves.
Chief executive, John Burns, said: “In October we introduced a new process for the management of Significant Adverse Event Reviews (SAERs).
“This was developed with the
full engagement of our staff, and reinforced by training to ensure that staff, families and patients are supported during reviews.” And he added: “NHS Ayrshire and Arran is committed to delivering the improvements to the Significant Adverse Event process.”
Meanwhile, the man who led the probe into Ayrshire’s faltering health service admits there are “material weaknesses” in the way it’s run.
Robbie Pearson fronted the Healthcare Improvement Scotland inquiry into the missing critical incident reports.
Their review blasted Ayrshire and Arran bosses for a “lack of accountability”.
And he said: “We identified material weaknesses in the system of managing significant adverse events reviews. Many of these relate to document control and systems of governance.
“However, the review group felt that the more substantial shortfalls related to staff involvement, action planning and the dissemination of wider learning.”