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.