4 Conclusion
147. Our inquiry has considered a complicated and
changing landscape of enormous importance to some people and potential
consequence to anyone. Despite pockets of best practice, good
intentions and strong leadership, clinical incident investigation
and complaints handling fall far short of what patients, their
families, clinicians and NHS staff are entitled to expect. A culture
of defensiveness and blame, rather than a positive culture of
accountability, pervades much of the NHS. Despite the efforts
to implement change, the same atmosphere extends to the Parliamentary
and Health Service Ombudsman, which also needs to change.
148. Clinical incident investigations are often too
slow, substandard and in too many cases they exclude patients.
No body currently exists to improve them, and nobody is accountable
for their quality at a national level or for ensuring that lessons
are learned across the NHS. We have identified three key features
the proposed new independent patient safety investigation body
must have. These are, first, confidentiality, in offering a safe
space to talk about what went wrong; second, independence of the
rest of the system; and third, transparency, in that its reports,
findings and recommendations must be published and disseminated.
149. Our aim in making these proposals is to improve
the system to reduce unnecessary suffering among patients and
their families in future. The next Government must reform the
structures as well as continuing to lead by example in driving
culture change. Patients and NHS staff deserve to have incidents
investigated properly, without the need to find blame, and regardless
of whether a complaint has been raised.
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