Email dated 21/01/2026
Holyrood Parliament re Critical Incident Reviews/Serious Adverse Event Reviews
Dear Mr Hamilton,
After meeting you at the recent Scottish Parliament round table event chaired by Stephen Kerr MSP we were very pleased to see the major article in the Sunday Post by Marion Scott (28/12/25) where you were severely critical of Scottish NHS boards for their lack of transparency in reporting maternity deaths and the current non-existence of SAER's (Serious Adverse Event Reports) on any board websites; Watchdog: Grieving families deserve transparency over baby deaths
We would like to additionally point out to you some aspects of the law which pertain to this deliberate national cover-up of hospital deaths and SAER's that have an important and direct bearing on how and why this national scandal continues to persist in Scotland. This is why SAER's are being deliberately covered up - in hundreds of cases not even being carried out or recorded! - and how health boards get away with it. No-one is holding them accountable or making them comply with the law.
We would agree that it is your role to hold these health boards to account and make them comply with the law. Here is the law as it stands;
SAER and the Law
Legal Context
Since 1974 UK-wide legislation has required the safety of patients, of those in maternity services, and of those in social care. This is with the Health and Health and Safety at Work etc. Act 1974 (HSWA) sections 1 and 3(1) https://www.legislation.gov.uk/ukpga/1974/37/ enacted
It also required that compliance with this legislation was effectively regulated (by section
18). Usually by HSE.
HSWA is the UK means to comply with ECHR Article 3 Right to Life in relation to all work activities (employees and the public affected by them). It is also the means to ensure compliance with the same Article 3 of the Human Rights Act 1988 (HRA).
On assuming power at Holyrood, the SNP introduced the US approach to patient safety.
This required no application of the law to ensure safety and no regulator. It was and is wholly unlawful by HSWA, ECHR, and HRA; this is the ongoing IHI (Institute of Healthcare Improvement, Boston) approach. The SNP government unlawfully abolished the regulation of patient safety in 2012. This it did by abolishing the independent regulator of patient safety and by making an unlawful agreement with the overarching regulator HSE. That HSE would not act (‘unless forced to do so’).
This ultra vires ‘disregard the law’ position of the SNP government also applied to dangerous pathogens as in the SARS-COV-2 pandemic and in the vast number of healthcare acquired infection deaths. ASAP-NHS has been pointing this out since 2012.
The cost of the disregard of the law will be in the region of 40,000 unlawful deaths. This now looks a very conservative figure. In the last three months we have found that the government has been covering up in excess of 4,000 AKI (Acute Kidney Injury) deaths a year. Of which most would be preventable by complying with HSWA. In England and Wales AKIs are recognised as perhaps the biggest cause of preventable deaths in healthcare. In Scotland they are almost totally invisible.
ASAP-NHS are required to refer the matter to the European Court of Human Rights.
Other patient safety matters are subject to specific crime reports with Police Scotland. With the SNP government unlawfully running the systems of prosecution and the investigation of deaths these matters are being obstructed (it is very similar to your own case with Scot Gov over the Sturgeon Inquiry Evidence and the lengths that Scot Gov are going to obstruct you in this https://www.bbc.co.uk/news/articles/cgk8n18zpy8o ).
One such case is the ASAP-NHS corporate homicide case (01 March 2023 against the Scottish government for its homicidal/ unlawful actions on the SARS-CoV-2 pandemic which actively spread the dangerous pathogen).
Serious Adverse Event Reports (SAER’s)
It is the devolved statutory responsibility of the Scottish government and its direct ministerial report NHS Scotland to ensure the safety of patients and those in maternity services so far as is reasonably practicable.
This is required by UK-wide reserved legislation of sections 1 and 3(1) Health and Safety at Work etc. Act 1974 (HSWA). https://www.legislation.gov.uk/ukpga/1974/37/enacted This is the UK-wide means of complying with Articles 2 and 3 of ECHR and the Human Rights Act 1998. The overall responsibility lies with the Cabinet Secretary for Health under section 1 NHS Scotland Act and the First Minister. Within NHS Scotland the personal responsibilities lie with the CEO NHS Scotland, CEOs, chairs, and other senior management at Board level under sections 7, 36, and 37. All individual employees have responsibility under section 7. The UK-wide sentencing guidance is for custodial sentences on HSWA offences.
HSWA, ECHR and HRA require effective regulation of compliance with HSWA s3(1).
Legally this is HSE (by section 18 HSWA). Currently unlawfully HSE has an unlawful agreement with the Scottish government that it will not act. In this way patient safety deaths and incidents are systematically covered up by the government and HSE.
Health Improvement Scotland (HIS) is not a regulator – even though many people are mistaken in a belief that they are. It is an internal Scottish government Quality Assurance body. It does not do HSWA, ECHR or HRA.
Supporting HSWA is the mandatory Management of Health and Safety at Work
Regulations 1999 (MHSWR). These require effective management systems to ensure safety. These are explicitly the management control loop of ‘Plan’, ‘Organise’, ‘Control’, ‘Monitor’, ‘Review’ and so to ‘Plan’. The SAER system is part of the statutory system. It is major offence not to have effective systems. The SAER system is exceptionally poor. It disregards the binding standard of HSWA, and ECHR. It wholly fails to give an accurate picture of what incidents are taking place. Incidents are not reported.
Whole categories are almost totally missing - such as the very large number of AKI (Acute Kidney Injury) deaths, likewise healthcare acquired infections (see QEUH public inquiry and related deaths), and medication errors. There is the lack of analysis and learning to end repeats – such as the endless repeats on maternity deaths.
Patient safety incidents are not covered by RIDDOR reporting but most certainly are HSWA and HSE issues. Deaths are also covered by ECHR and HRA. They require an effective independent system of investigation. Unlawfully Scotland currently does not have this. Patient safety deaths and maternity deaths are covered by the binding Scottish Work-Related Deaths Protocol involving joint investigations by HSE, COPFS, and Police Scotland https://www.copfs.gov.uk/publications/work-related-deaths-a-protocol-for- liaison/html/ It applies to both workers and the public (such as on the Glasgow bin lorry disaster).
The patient safety deaths and maternity deaths are also required to be reported to COPFS under the ‘Reporting Deaths to the Procurator Fiscal Information and Guidance for Medical Practitioners’ https://www.copfs.gov.uk/for-professionals/reporting-deaths/
Procurator Fiscals and Lord Advocates have long known that this is not complied with and the deaths are covered up. We understand that they regard it as a major criminal offence to cover up such deaths. However, COPFS and NHS Scotland have the same governance under the Scottish First Minister, such as John Swinney. So, the massive unlawful cover up continues.
We are in the unique and unlawful position of deaths in Scotland not being handled according to Scots law, UK law, or international law. They are required to be handled by an independent and lawful HM Coroner system or the equivalent. That Scotland does not have a lawful independent system of investigating deaths, or of prosecutions, has now been referred by ASAP-NHS to the European Court of Human Rights (ECtHR). Existing binding ECtHR judgements confirm that the Scottish position is extremely unlawful.
Why are these laws not being complied with by health boards? And why are SAER's not available to the public?
We would be happy to meet with you to discuss these matters further.
Yours aye,
Rab Wilson for ASAP-NHS