Forth Valley Health Board Response

SHERIFFDOM OF TAYSIDE, CENTRAL AND FIFE AT FALKIRK

Court ref: ALO-B40-23

RESPONSE

on behalf of Forth Valley Health Board

to the

Determination by Summary Neil Bowie

in the

Inquiry into the death of Peter Carter

under the Inquiries into Fatal Accidents and Sudden Deaths etc (Scotland) Act 2016

To:  The Scottish Courts and Tribunals Service

Forth Valley Health Board, being a body to whom recommendations under section 26(1)(b) was addressed, do respond as follows.

1. Recommendation 1: NHS Forth Valley Health Board should conduct a review of the clinical oversight of test results within its laboratories with a view to establishing a system of parameters that increases clinical oversight of blood test results.  This should be undertaken within 6 months.

2. Response to Recommendation 1: Forth Valley Health Board (“FVHB”) established a Short Life Working Group (“SLWG”) to consider the recommendations. The SLWG reports to the Board’s Clinical Governance Working Group. The first three recommendations have resulted in a detailed action plan led by senior Laboratories management.

3. Additional Clinical Scientists will be required to allow an increase in clinical oversight to happen fully. That would allow an established rota to be put in place with an out of hours service. Funding has been agreed for an additional post and a submission to Recruitment made on 20 May 2025 to allow the post to be advertised.

4. A request has been made to the Clinical Lead for Laboratories at Fife Health Board (FHB) to perform a review of FVHB’s clinical reporting procedures (a Gap Analysis) to identify gaps in services or processes and allow improvement in delivery and outcomes. FHB has a comparative sized laboratory and is UKAS accredited. The Clinical Lead from FHB is to visit the laboratories at FVHB on 18 August 2025.

5. Contact has been made with other Scottish laboratories to request details of their systems of parameters for clinical review of system test results to enable FVHB to develop local clinical oversight. This will be discussed with the Clinical Lead from FHB at the visit on 18 August 2025. FHB has also shared its clinical review parameters with FVHB.

6. Additional staff will be required, and planning on staffing will be actioned depending on the outcome of the external peer review. There is a requirement for an additional Biomedical Scientist to allow for further expertise and training of staff around technical validation, and to provide specialist knowledge and support to all staff in the department. This is in progress.

7. Recommendation 2: NHS Forth Valley Health Board should urgently increase awareness of the set criteria applied to the reporting of abnormal blood test results to all clinicians.

8. Response to Recommendation 2: FVHB’s Communication of Critical Results Policy is available on the staff intranet. This will be shared again with staff via the intranet to raise awareness. This is in progress with the FVHB Communications Team. The policy was also shared and discussed at the Community Diagnostics User Group (“CDUG”) meeting on 29 May 2025.  Prison Services will be invited to this group going forward. Both Laboratory handbooks are also available on the intranet for the acute site. The CDUG has confirmed that GPs can access the Laboratory handbooks on the intranet.

9. Recommendation 3: As part of its ongoing review into its laboratory system, NHS Forth Valley Health Board should consider whether the set criteria for phoning in test results to requesting clinicians should account for any change in the patient’s location regardless of whether the findings are new or unexpected.

10. Response to Recommendation 3: FVHB have updated their Standard Operating Procedures (“SOP”) in relation to the handling of urgent samples and reporting results that exceed alert levels. Where a patient’s location changes from secondary care to primary care, or vice versa, abnormal results will be phoned regardless of previous abnormal results. This change in policy took effect on 26 May 2025, and has been communicated to staff verbally at staff meetings on multiple occasions. An email was sent to all staff confirming the changes. The same change has been made to the Haematology SOP and the updated SOP was issued to staff on 3 June 2025.

11. Recommendation 4: NHS Forth Valley Health Board should carry out a review of its discharge process for patients to a prison setting increasing awareness of the checklist created by Dr Sayers, increasing awareness of medication available in a prison setting and consideration of including a requirement that outstanding test results are reviewed prior to discharge.

12. Response to Recommendation 4:   This recommendation sits with the Acute Hospital leadership team and is being progressed in parallel with other discharge work, the totality of which reports to the Unscheduled Care Programme Board, chaired by the Medical Director.