2The Investigative Landscape in the NHS in England
PHSO Report ‘Learning from Mistakes’
9.The case study of Sam Morrish’s tragic death in 2010 is at the heart of the PHSO’s report. In summary, Sam Morrish died of sepsis after a series of mistakes were made between his first displaying flu-like symptoms and his eventual death in the early hours of 23rd December 2010. The investigations into his death variously involved 5 organisations, none of which, according to the PHSO’s report, satisfactorily determined the root causes of failings in Sam Morrish’s case or showed signs of the ‘learning’ approach that is so essential for incorporating lessons into practice and procedure in order to prevent the same mistakes being repeated in future.13 As the PHSO’s first report in 2014 found, these organisations also failed to conclude that Sam Morrish’s death was ‘avoidable’ in the first place, as it was later found to have been.14
10.In its ‘Learning from Mistakes’ report, the PHSO reiterates the five areas for improvement identified by the recent CQC ‘Briefing: Learning from serious incidents in NHS acute hospitals’ :
- Serious incidents that require full investigation should be prioritised and alternative methods for managing and learning from other types of incident should be developed.
- Patients and families should be routinely involved in investigations.
- Staff involved in the incident and investigation process should be engaged and supported.
- Using skilled analysis to move the focus of investigation from the acts or omissions of staff, to identifying the underlying causes of the incident.
- Using human factors15 principles to develop solutions that reduce the risk of the same incidents happening again. There are also improvements to be made in communication, coordination and governance within and across organisations.16
11.In ‘Learning from Mistakes,’ the PHSO also reiterates its point from its 2015 report, ‘A Review Into the Quality of NHS Investigations,’ that training and accrediting sufficient investigators to operate locally is crucial to the long term improvement of local investigations.17 In ‘Learning from Mistakes,’ the PHSO further says that it believes there is a need for the role of NHS complaint managers and investigators to be better recognised, valued and supported.18
12.In their evidence, NHS England, which sets the priorities and direction for the NHS in England, confirmed that they recognised the issues identified by the PHSO’s report. The report, they said
provides robust analysis of issues such as investigative procedures and gaps, communication and coordination between different health organisations, communications between those organisations and the family and how the investigation processes can be improved.19
Culture
13.In the first evidence session of our follow-up inquiry into the PHSO’s ‘Learning from Mistakes’ report on 8th November 2016, Scott Morrish outlined his view of the ‘blame culture’ in the NHS in England, including some of the negative implications of that culture and why it needs to be converted into one in which ‘learning’ is central:
We need to shift the whole focus away from the blame and the shame and the worries that go with that and the silence that it leads to. We need to shift that to one where the expectation is learning, no matter what happened. Whether it is good or bad we can learn and improve and have an expectation of supporting staff and supporting families, not pitting us against each other.20
14.In ‘Learning not Blaming,’ the Government’s response to PASC’s report on ‘Investigating clinical incidents in the NHS,’ the Government argued that the health service should seek to tackle this blame culture. They said that the NHS “must embrace a culture of learning rooted in the truth, a culture that listens to patients, families and staff and which takes responsibility for problems rather than seeking to avoid blame.”21
15.When he spoke to us, the Health Minister, Rt Hon Philip Dunne MP, reiterated the Department of Health’s ambition to tackle the blame culture in the NHS in England: “what we are endeavouring to do is to change the entire culture of the NHS towards a learning culture and we start with the experience of the patient […] who is making the complaint.”22
16.It is difficult to monitor and measure this cultural aspect of the healthcare system. In this respect, the CQC’s Prof Sir Mike Richards pointed out that the NHS Staff Survey, conducted annually, provides a good basis from which to extrapolate some of the issues with the investigative culture in the health service that the PHSO’s ‘Learning from Mistakes’ report exposes. Tellingly, the survey reports that when asked whether their organisation treated staff involved in near misses, errors and incidents fairly, less than a half of all staff (43%) reported this was the case.23
17.We asked witnesses about action being taken to address this culture of fear and blame that inhibits open investigations and learning from mistakes. We sought to probe the extent to which the Department of Health, and the health service more broadly, had a coherent strategy for moving the system towards a learning culture. Within this, the Committee sought to determine which national bodies would be responsible for the different parts of this strategy, including the soon to be established HSIB, NHS Improvement (responsible for driving improvements within foundation trusts and NHS trusts), and the CQC. Central to our concern in this area is how the proposed ‘safe space’ principle for investigations will be secured in legislation and what the implications of its introduction, both for and beyond HSIB, will be on the attitudes and behaviours that influence the health service’s investigative processes. This report makes clear that the ‘safe space’ for HSIB requires legislative underpinning in order to contribute effectively to the development of a learning culture in the NHS in England. At the same time, it also expresses our severe reservations about the negative impact a premature expansion of the ‘safe space’ beyond HSIB may have.
Multiple body investigations and the involvement of patients and families in investigations
18.The PHSO’s ‘Learning from Mistakes’ report welcomes the introduction of HSIB as a positive step towards tackling some of the issues it uncovered with regard to the organisation of multiple-body investigations and an overall culture of blame that undermines the ability for investigations to lead to learning. This section sets out the key issues within the investigative processes in the NHS in England. The intended role and place of HSIB within that landscape is set out in the next section.
19.NHS England highlights in its evidence that in 2015, the Patient Safety Team published the NHS Serious Incident Framework (previously published in 2010 and 2013).24 This framework outlines the process whereby NHS organisations ensure they “appropriately report, investigate and respond to serious incidents so that lessons are learned.” This framework was introduced to reflect changes in the NHS landscape in England and improve cooperation between different bodies conducting investigations. The overall aim is to ensure investigations lead to a clear analysis of why clinical incidents occurred and what can be done to minimise the risk of similar incidents occurring in future.
20.Despite this, much of our written evidence for this inquiry points towards continuing failings in the investigations process, including evidence that clinical incidents do not always prompt an open learning-focused investigation, particularly when multiple organisations are involved, as was the case for Sam Morrish’s death. In ‘Learning, candour and accountability: A review of the way trusts review and investigate the deaths of patients in England,’ the CQC reports more broadly that “Organisations work in isolation, only reviewing the care individual trusts have provided prior to death.”25
21.In their written evidence to our Learning from Mistakes inquiry, Healthwatch England, a consumer champion for health and social care, point out a number of perceived flaws in communication and coordination across the healthcare system that they uncovered by conducting a series of national polls. Many of these issues relate to the complexity of the various investigative bodies that deal with complaints, and how those bodies engage with patients and families. The key issues Healthwatch England highlights are that patients and families:
- Were not given the information they needed to complain;
- Did not have confidence in the system to resolve their concerns;
- Found the complaints system complex and confusing;
- Needed support to ensure their voices were heard;
- Needed to know that health and care services would learn from complaints.26
22.In our first evidence session on the PHSO’s ‘Learning from Mistakes’ report on 8th November 2016, Scott Morrish focused on how the blame culture in the NHS in England was part of the reason for the inadequate involvement of families and patients in the investigative process:
In our circumstances, basically the poor governance allowed control to rest in a very small number of hands, and for a number of reasons, including fear and poor process, they basically did not want to be confronted with those other perspectives. It [the Morrish family’s perspective] challenged identity and their understanding of themselves, and it was deeply uncomfortable.27
23.Healthwatch England further notes that they found that “70 different organisations” dealt with complaints, creating “a complex and frustrating landscape for patients, service users, carers and families to navigate.”28 Their report, ‘Suffering in Silence,’ offers additional context for these findings. In this report, they also conclude that “despite a weight of reports on the matter,” people find the complaints process complicated, frustrating, and ineffective.29
24.In its evidence to this inquiry, Healthwatch England picked up on the need for patients and families to be involved more consistently and more extensively throughout the investigations and complaints processes. This was especially important, they argued, as a means of informing “patients and the wider public about how the NHS is learning” in order to build “wider public understanding and confidence in how feedback more generally is being used to drive improvement, both at a local and national level.”30
25.Commenting specifically on how the existing confusion surrounding investigations can be tackled for families and patients, The UK Sepsis Trust, a charity founded in 2012 to tackle sepsis, recommended that there should be “a framework against which the design, governance, transparency, fairness, timeliness and effectiveness of an investigation can readily be judged in order to identify areas for improvement.”31
26.The complexity of the investigative landscape contributes to a wider sense that the NHS in England struggles to coordinate its efforts to learn from mistakes and errors when they occur. Furthermore, given that families and patients find the investigative process difficult to navigate and feel excluded from investigations, their valuable input is not effectively engaged during investigations and they are left unaware of whether or not the system has learned from the incidents it investigates. As Mr Morrish’s evidence suggests, the exclusion of patients and families may provide further evidence of the blame culture that permeates the NHS in England. This results in patients and families being treated as problems that must be managed. Instead, as Dr Shorrock’s evidence to the Committee suggests, patients should be treated as experts in their own cases and, therefore, as key sources of information to determine why mistakes occurred.32
27.It is clear from the evidence reviewed during the course of this inquiry that the investigative processes in the health service in England remain obscure and difficult to navigate for patients and families. As a result, patients and families are excluded by the system, which must become open and learning-focused if investigations are to lead to positive changes in the system. Families and patients should, as a matter of course, be included in investigations and should feel confident that lessons will be learned as a result of clinical incidents.
13 Learning from mistakes, Parliamentary and Health Service Ombudsman, July 2016, p. 6.
14 An avoidable death of a three-year-old child from sepsis, Parliamentary and Health Service Ombudsman, June 2014.
15 In his evidence to us, Dr Shorrock referred to some of these human factors that influence working conditions in healthcare: “All human work is driven by demand, which results in pressure when resources are inadequate or when constraints are inappropriate. All human work is characterised by basic goal conflicts between, for instance, the need on the one hand to be thorough in checking, diagnosing and executing procedures, and the need to be efficient.” (Q24) Human factors principles, in this context, are therefore taken to mean those environmental and organisational factors that influence an individual’s ability to do their job without making mistakes.
16 Learning from Mistakes, Parliamentary and Health Service Ombudsman, July 2016, p. 7.
17 Learning from Mistakes, Parliamentary and Health Service Ombudsman, July 2016, p. 7.
18 Learning from Mistakes, Parliamentary and Health Service Ombudsman, July 2016, p. 7.
21 Department of Health, Learning not Blaming: The government response to the Freedom to Speak Up consultation, the Public Administration Select Committee report ‘Investigating Clinical Incidents in the NHS’, and the Morecambe Bay Investigation, July 2015, p. 12.
23 The survey is administered annually so staff views can be monitored over time. Participating organisations must, as a minimum, select a random sample of 1,250 employees to take part in the survey. The survey can get a representative picture of views within the organisation by taking a random sample which reduces the burden on staff within an organisation, as not all staff have to take part. Organisations may choose to survey an extended sample of staff or all their staff (a census approach). NHS Staff Survey 2015 Briefing Note, p. 10.
24 NHS Serious Incident Framework, NHS England, implemented in April 2015.
25 ‘Learning, candour and accountability: A review of the way trusts review and investigate the deaths of patients in England,’ Care Quality Commission, December 2016, p. 39.
29 Suffering in silence: Listening to consumer experiences of the health and social care complaints system, Healthwatch England, October 2014, p. 32.
27 January 2017