6Improving investigation and learning, in particular from serious incident investigations
Box 5: PHSO Recommendation Five
Both NHS Improvement and NHS England have a leadership role to play in supporting local NHS providers and CCGs to conduct and learn from serious incident investigations, including those that are complex and cross organisational boundaries. NHSE and NHSI should use the forthcoming Serious Incident Framework review to clarify their respective oversight roles in relation to serious incident investigations. They should also set out what their role would be in circumstances like the Harts, where local bodies are failing to work together to establish what has happened and why, so that lessons can be learnt.
Source: How NHS eating disorder service are failing patients, Parliamentary and Health Service Ombudsman, December 2017, p 17
Background to the recommendation
70.The Ombudsman’s report details how Nic Hart had been in correspondence with six organisations over a year and a half yet none of them worked towards a coordinated investigation of Averil Hart’s death, which is something the PHSO has encountered “time and time again”.82 The Patient Experience Library, in written evidence, stated this issue is systemic across the NHS and “a common factor throughout is a failure to hear from patients and bereaved relatives, and to understand the patient experience.”83 The issue of NHS learning from investigations is something that we, and our predecessor committees, have taken an active interest in.84
Progress on the recommendation
71.The Government described work under this recommendation as being “underway” and the following steps have been taken:
- NHS Improvement’s work with regional teams across NHS Improvement and NHS England to design a new system for oversight and support for incident management, including incidents that may require cross system investigation.
- In December 2018, NHS Improvement reported that they had conducted an engagement exercise to inform a review of the Serious Incident Framework for the NHS between April and July 2018.
- Work has been undertaken to develop new regional functions which support the overarching patient safety strategy,85 the public consultation on which closed on 15 February 2019.
- Finally, a new Serious Incident Framework is to be published in the Spring of 2019.86
72.The PHSO, in written evidence, told us that the feedback NHS Improvement had received, as part of its engagement on revising the Serious Incident Framework, demonstrated the need for a “fundamentally different approach to the management of serious incidents.”87 This was likely to “support the development of broader systems, processes, skills and behaviours that enable an appropriate response to patient safety incidents.”88 While awaiting the publication of the revised framework, the PHSO welcomed NHS Improvement’s direction of travel but noted the need for clear funding and timescales for implementation.89
73.The Care Quality Commission told us that they had found evidence that some trusts had “established more robust practices to review, investigate and share learning from deaths” but progress was variable between trusts.90 The Commission continued that for further progress to be made:
the culture of many organisations needs to improve and there is a need for further specialist training, engagement with bereaved families, and guidance and support from trusts and other bodies is required to encourage more openness and learning across the NHS.91
74.In oral evidence Dr Kendall told us about the need to encourage senior doctors to talk about their mistakes:
One of the things that the previous Secretary of State did, I thought very well—I used to go around with him to visit mental health trusts and it was all about patient safety and mental health—was he began a whole programme of patient safety in mental health. One of the things that he did was that he got us senior doctors, including from the Royal College of Physicians and others, to stand up and talk about their experiences of making a mess of things. We have to create a culture in which we are all a lot more honest and that does include senior doctors at the top being honest about where we have made mistakes.92
75.As part of our roundtable discussions with people who had lived experience of eating disorders, it was made clear that there was a need for the NHS to move from prioritising short-term reputation management to focusing on facilitating learning and longer-term improvements.
Health Service Safety Investigations
76.Following work by our predecessor Committee,93 the creation of the Healthcare Safety Investigation Branch (HSIB) which became operational on 1st April 2017, was a welcome development in the area of healthcare investigations. The purpose of the organisation, which is funded by the Department for Health and Social Care but operates independently from it and NHS Improvement, is to improve safety through effective and independent investigations that don’t apportion blame or liability.94 In written evidence to this inquiry, HSIB informed the Committee that, alongside investigations, it has spent the first two years “developing and refining our methodology” for conducting investigations through developing a seven-point “framework for professionalising safety investigations in the NHS.”95
77.The work of the Joint Committee on the Draft Health Service Safety Investigations Bill was concluded in August 2018 with the publication of its report.96 The Bill would establish the full statutory independence of HSIB and would allow it to conduct national investigations under protected disclosure. This provision, commonly known as ‘safe space’, would enable NHS staff to share their experience of a patient safety incident without fear of reprisal. Importantly, it would not prevent HSIB from sharing information with families, regulators or organisations about an incident or to address immediate risks to patient safety.97 The Health Service Safety Investigations Bill has not yet been introduced to Parliament.
78.Investigations into, and NHS learning from, serious incidents is essential to helping ensure that the circumstances leading to avoidable deaths do not reoccur. It is heartening to hear from the Care Quality Commission that some trusts are establishing more robust practices for investigating and learning from deaths but such change must be made throughout the whole of the NHS. Cultural change is essential to achieve this. We believe the Care Quality Commission’s inspections provide one way for the NHS to determine the progress it is making in culture change; namely the shift from a closed and defensive blame culture to one of openness, willingness to hear and tell the truth, and to learning from mistakes to avoid future harm to patients. It is essential that the NHS moves from a culture which falls into short-term reputation management to one which facilitates open learning and longer-term improvements to service provision. The NHS should further consider how it can assess the progress it is making in changing the culture surrounding investigations and learning. Such cultural change must be regarded as a high priority.
79.We welcome the initial work of Healthcare Safety Investigation Branch (HSIB) in investigating the causes of clinical incidents without attributing blame and in order to disseminate learning for the future and the seven-point “framework for professionalising safety investigations in the NHS”. We call on the Government to introduce the Health Service Safety Investigations Bill as soon as possible in order to provide HSIB with statutory powers and independence, and to enable it to provide a statutory ‘safe space’ for clinicians and patients and their families to speak freely, like other safety investigation bodies.
82 Ignoring the Alarms: How NHS eating disorder service are failing patients, Parliamentary and Health Service Ombudsman, December 2017, p 17
84 Public Administration and Constitutional Affairs Committee, Seventh Report of Session 2016–17, Will the NHS never learn? Follow-up to PHSO report ‘Learning from Mistakes’ on the NHS in England, HC 743; Public Administration and Constitutional Affairs Committee, First Report of Session 2016–17, PHSO review: Quality of NHS complaints investigations, HC 94
85 Developing a patient safety strategy for the NHS: Proposals for consultation, NHS Improvement, December 2018
86 Department of Health and Social Care, Health Education England and the National Institute for Care Excellence, IDF0017
93 Sixth Report of the Public Administration Select Committee, Session 2014–15, Investigating clinical incidents in the NHS, HC 886.
95 Healthcare Safety Investigation Branch, IDF0018;. See the full framework attached in annex to their evidence.
96 Report of the Joint Committee, Draft Health Service Safety Investigations Bill: A new capability for investigating patient safety incidents, Session 2017–19, HL Paper 180 HC 1064.
Published: 18 June 2019