House of Commons - Investigating clinical incidents in the NHS

Investigating clinical incidents in the NHS - Public Administration Contents

1 Introduction

1. The Public Administration Select Committee (PASC) scrutinises the work of the Parliamentary and Health Service Ombudsman (PHSO), which is the final adjudicator of NHS complaints in England.[1] Many of the PHSO's adjudications are based on evidence about clinical incidents. There has been increasing concern that some of its adjudications have not been based on reliable evidence, and that this reflects an inadequate capacity for investigating and reporting on clinical incident investigations across the whole of the NHS. This Report follows our inquiry into how the system for investigating clinical incidents is working in the NHS and what can be learned from other sectors that need to investigate safety lapses or incidents that cause injury or death. Our inquiry was prompted by a paper on this topic in the Journal of the Royal Society of Medicine by Carl Macrae and Charles Vincent.[2] Our report is addressed to the NHS in England, but we believe our findings are also relevant to the rest of the health sector, and to the NHS in Scotland, Wales and Northern Ireland.

Background

2. A number of reviews and reports in recent years provide the context for this inquiry. These have focused on the need to create systems and cultures that support open and effective learning in the NHS. Following a public inquiry into failings at Mid-Staffordshire NHS Foundation Trust between January 2005 and March 2009, Robert Francis QC published his final report on 6 February 2013. It concluded that a fundamental culture change was needed.[3] In July 2013 Professor Sir Bruce Keogh, the NHS Medical Director for England, published his review of the quality of care and treatment provided by trusts that were persistent outliers on mortality indicators.[4] This called for a concerted improvement effort and a focus on clear accountability. In August 2013 the Department of Health published the report of Don Berwick's review into patient safety, which studied the Francis report and distilled the lessons learned for the Government and the NHS, and changes needed.[5] It called for the NHS to become "a system devoted to continual learning and improvement of patient care, top to bottom and end to end".[6] The Government published its response to Robert Francis' inquiry in January 2014.[7] This stated that there would be stronger professional responsibility, and openness about mistakes and 'near misses'; "following the example of the airline industry in building an open culture that learns from errors and corrects them."[8]

3. There have been a number of policy developments since we announced our inquiry on 17 December 2014. New patient safety initiatives have been announced, and the Government has accepted the need for an independent safety investigation unit. On 11 February this year the Department of Health published Culture change in the NHS, which stated that:

It makes sense to concentrate and consolidate national expertise and capability on safety within a single organisation that can provide strategic leadership across the whole healthcare system.[9]

4. The Government accepted Sir Robert Francis' recommendation that trusts should appoint a person to receive concerns and offer advice, to ensure cases are properly investigated and issues addressed without repercussions for the person who raised an issue.[10] These will be known as Freedom to Speak Up Guardians. The Secretary of State for Health explained these would be "part of the organisation but just there, so that, if you do not want to tell your line manager, you have someone else you can talk to in the Trust."[11] There will also be, he explained, a national Freedom to Speak Up guardian, "so there is someone outside the hospital if you ultimately needed it."[12]

5. In the House of Commons on 3 March 2015, following his appearance to give evidence before us on this inquiry, the Secretary of State for Health Jeremy Hunt MP said he was asking the Director of Patient Safety in NHS England, Dr Mike Durkin, to draw up and publish "much clearer guidelines for standardised incident reporting".[13] He continued:

But I also believe the NHS could benefit from a service similar to the Air Accidents Investigation Branch of the Department for Transport. Serious medical incidents should continue to be instigated and carried out locally, but where trusts feel they would benefit from an expert independent national team to establish facts rapidly on a no-blame basis they should be able to.[14]

6. The relationship between complaints, clinical incident investigation, and patient safety is complex. All serious patient safety incidents are supposed to be investigated by healthcare provider organisations, as the Serious Incident Framework sets out.[15] However, at present, patients or their relatives often need to complain in order to prompt the investigation of an incident.[16] Patients often do not complain due to lack of confidence in complaints handling, so that safety issues go unresolved.[17] Poor investigation of clinical incidents locally leads to more complaints being escalated to the Parliamentary and Health Service Ombudsman.[18]

7. The comprehensive evidence base that would be provided to the Ombudsman if local investigations were more effective would speed up the Ombudsman's work, allowing it to publish its findings more quickly.[19] It would also enable more complaints about clinical incidents to be resolved without the PHSO's intervention. Complaints may be unfounded, and doctors may be negligent. But it is usually safe to assume good faith. Murray Anderson-Wallace and others, a small group of people with personal experience of avoidable harm in healthcare, wrote to us to say that "in the vast majority of circumstances citizens and healthcare staff share the same goals and aspirations. Both are significantly affected by poor quality investigation and adversarial approaches to avoidable harm."[20] Things can usually be put right through proper complaints handling and effective investigations. Effective investigations can reduce the number of complaints.[21] The Ombudsman, Dame Julie Mellor, described the relationship as follows:

There is an under-reporting of incidents and therefore an under-investigating of incidents, and therefore continuing risk to patient safety and the learning not happening.[22]

8. Written submissions and transcripts of our three oral evidence sessions are available on our website at www.parliament.uk/pasc.We are grateful to all those who gave evidence and to our Specialist Adviser, Dr Carl Macrae, for his help with this inquiry.[23]

9. This inquiry has received much evidence concerning individual cases that we cannot address individually, but which together paint a grim picture of grief and anger caused by denial, defensiveness and evasion. We have read all these submissions carefully in order to see what we can learn from them. We pursue this topic in the hope of achieving quicker and more effective resolution of incidents of clinical failure locally, leading to faster learning and more positive change, without the need for a complaint, and therefore a substantial reduction in the number of people whose cases reach as far as the Ombudsman.

10. We are grateful for the openness and dialogue we have had with the Secretary of State for Health, who has become an advocate for a new body along the lines we have been discussing.

1 Error! Bookmark not defined. Back

2 Macrae C and Vincent C, 'Learning from failure: the need for independent safety investigation in healthcare' Journal of the Royal Society of Medicine; 2014, 107(11) 439-443 Back

3 Error! Bookmark not defined., HC 947, February 2013 Back

4 NHS Choices, Error! Bookmark not defined., July 2013 Back

5 Department of Health, Error! Bookmark not defined., August 2013 Back

6 As above Back

7 Department of Health, Error! Bookmark not defined., January 2014 Back

8 As above Back

9 Department of Health, Error! Bookmark not defined., February 2015 Back

10 Sir Robert Francis QC, Error! Bookmark not defined., February 2015 and Hansard (2015) 3 Mar : Column 835 Back

11 Q 284 Back

12 As above Back