Annex
Current key approaches to healthcare investigation
Dr Carl Macrae and Professor Charles Vincent outlined
a number of approaches to healthcare investigations in their article
'Learning from failure'.[306]
These are:
1. Local independent investigation or review
· Initiated
by NHS trust involved in serious incident or concern.
· Typically
led by external senior clinician or senior healthcare managers
undertaking site visits, interviews and data and documentary review.
· Duration
of several months.
· Investigation
reports to the trust, usually with disclosure of findings to patients,
relatives and carers as well as commissioning and regulatory bodies
but not commonly publicly reported.
· Examples:
Independent Review on the care given to Mrs Elaine Bromiley on
29 March 2005.
2. National independent investigation
· Initiated
by and reporting to the Department of Health.
· Typically
led by a senior clinician supported by a small team undertaking
interviews and data and documentary review.
· Duration
around 1 year.
· Investigation
reports to the Department of Health and final findings reported
in public.
· Examples:
University Hospitals of Morecambe Bay NHS Foundation Trust Maternity
and Neonatal Services Investigation, 2014.
3. Independent inquiry
· Initiated
by and reporting to the Secretary of State. Typically led by an
experienced legal professional supported by secretariat and expert
panel.
· Duration
typically 1-2 years.
· Final
report including recommendations and lessons learnt is usually
made public in its entirety.
· Example:
Independent Inquiry into care provided by Mid Staffordshire NHS
Foundation Trust, 2010.
4. Public inquiry
· Initiated
by and reports to the Secretary of State.
· High
profile enquiries typically led by an experienced legal professional
supported by secretariat and expert panel.
· Duration
typically 2-3 years.
· Final
report and recommendations made public.
· Examples:
The Mid Staffordshire NHS Foundation Trust Public Inquiry, 2013;
Bristol Royal Infirmary Inquiry, 2001.
5. House of Commons Health Committee Investigation
· Initiated
by parliamentary committee in response to serious safety concerns
or performance issues.
· Conducted
by members of parliamentary committee.
· Duration
typically 1-2 months.
· Evidence,
final report and recommendations made public.
· Examples:
Urgent and Emergency Services, July 2013.
6. Keogh Mortality Review
· Initiated
by Prime Minister and Secretary of State for Health in response
to serious concerns regarding trusts deemed to be persistent outliers
on mortality indicators.
· Led
by senior clinician supported by large team of experts.
· Duration
over several months.
· Findings
and recommendations reported publicly.
· Example:
Review into the quality of care and treatment provided by 14 hospital
trusts in England.
7. Care Quality Commission regulatory investigation
· Initiated
by the regulator in response to concerns and indications of poor
performance.
· Led
by regulatory investigators supported by external expert advisors.
· Duration
typically of 3-6 months.
· Final
report and recommendations published publicly.
· Example:
Investigation report - University Hospitals of Morecambe Bay NHS
Foundation Trust, July 2012
8. Parliamentary and Health Service Ombudsman
investigation
· Initiated
in response to patient, family or carer complaints about the administration,
investigation, handling and remedy of serious safety events.
· Conducted
by the Ombudsman.
· Typical
duration around 1 year.
· Example:
Four investigation reports concerning the University Hospitals
of Morecambe Bay NHS Foundation Trust, February 2014
9. Royal College invited review
· Initiated
at the request of a trust to review aspects of safety and quality
of services.
· Typically
conducted confidentially and led by a small team of experts and
clinicians through site visits and data and documentation reviews.
· Duration
can be 3-6 months.
· Findings
and recommendations are reported to the trust in private, and
may be shared by the trust with commissioners and regulators.
· Example:
Royal College of Anaesthetists Anaesthesia Review Team
10. NHS England led Incident Management Team Review
· Initiated
by NHS England in response to failings identified during regulatory
inspection.
· Typical
duration of 1 month. Rapid investigation into serious failings.
· Led
by national commissioning body (NHS England) and including regional
and local commissioning groups, clinical networks, county council
and expert members through clinically led visits and review.
· Reported
publicly.
· Example:
Report into the Immediate Review of Cancer Services at Colchester
Hospital University NHS Foundation Trust, 2013
11. NHS England Rapid Response Review
· Initiated
by NHS England in response to Quality Surveillance Group concerns,
or due to concerns raised during a regulatory inspection.
· Led
by experienced clinicians through site visits of several days
and review over several weeks.
· Findings
and recommendations publicly reported.
· Example:
Rapid responsive review into the quality of care and treatment
provided by Wye Valley NHS Trust, 2013
12. NHS England Services Review
· Initiated
by national commissioning body (NHS England) in response to urgent
concerns raised regarding safety issues from mortality data, patient
complaints and concerns.
· Involves
action to temporarily suspend services.
· Duration
of several months, including site visits and mortality case review.
· Key
findings publicly reported.
· Example:
Leeds Children's Heart Surgery Services Review, 2013-2014
306 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
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