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Speed up plans for new patient safety investigation body, urge MPs

And carry out ‘fundamental reform’ of health service ombudsman system

Caroline White

Friday, 27 March 2015

The government should speed up plans to set up a national independent patient safety investigation body, and fundamentally reform the “defensive” health ombudsman system, concludes a report* published by the Public Administration Select Committee.

The current ‘tangled’ approach to looking into clinical incidents and complaints must be replaced with a more rational and easy-to-understand system, it says.

More than 10,000 serious incidents are reported to NHS England, out of a total of 1.4 million mostly low-harm or no-harm incidents annually, and during  2013-14 NHS England received 174,872 written complaints. The government’s own estimates indicate that there are 12,000 avoidable hospital deaths every year.

The NHS Litigation Authority's latest estimate of clinical negligence liabilities is £26.1 billion. The Francis Inquiry into the Mid Staffordshire NHS Foundation Trust cost £13.6 million.

“Patients and NHS staff deserve to have untoward clinical incidents investigated immediately at a local level, so that facts and evidence are established early, without the need to find blame, and regardless of whether a complaint has been raised,” says the report.

But this will require “strengthened investigative capacity locally in most of the NHS, supported by a new, single, independent and accountable investigative body to provide national leadership, to serve as a resource of skills and expertise for the conduct of patient safety incident investigations, and to act as a catalyst to promote a just and open culture across the whole health system,” it says.

The inquiry on which the report is based found examples of good practice in some areas, but the processes involved are far too complicated, take too long, and focus on avoiding blame and financial liability, says the report.

Too many organisations have a role in complaints and safety investigations, meaning that there is no systematic and independent approach, says the report. And there’s no single body or individual responsible and accountable for the quality of the investigations or for ensuring that lessons are learned

In response to the inquiry, the health secretary has asked Dr Mike Durkin, Director of Patient Safety in NHS England, to look at the possibility of setting up a national independent patient safety investigation body.

The report emphasises that this body must offer strong protections to patients and staff, so they can talk freely about what has gone wrong without punitive reprisals. Second, it must be independent of providers, commissioners and regulators, and so able to investigate whether and how the system as a whole was instrumental in contributing to clinical failure. Third, for transparency and accountability, and to drive learning and improvement, it must have the power to publish its reports and to disseminate its recommendations. It should be for the Care Quality Commission and other executive, regulatory and commissioning bodies to ensure they are implemented, says the report.

There will have to be clear criteria for deciding which incidents it should investigate, to avoid being overwhelmed by the large number that require routine investigation across the NHS.

Every CCG should have an independent medical examiner, to look into hospital deaths, and alert the coroner to cases of concern. These examiners should refer cases for investigation to the proposed new body, it recommends.

And it calls for “fundamental reform” of the Ombudsman system, arguing: “There are serious questions about the capacity and capability of the Ombudsman's office, in particular in relation to complaints involving clinical matters.”

“We are aware of considerable anguish and disquiet where Parliamentary and Health Service Ombudsman investigations fail to uncover the truth, and of pain inflicted by the Ombudsman's defensiveness and reluctance to admit mistakes,” it adds.

Complainants saw themselves “a critical friend of the NHS, not an enemy,” commented Katherine Murphy, Chief Executive of the Patients Association. She added: “It is time for the NHS to stop compounding the grief and distress caused to families and truly listen, practice what you preach and respond to what patients are saying.”

Dr Michael Devlin, head of professional standards and liaison at the MDU, said that the defence body had seen a deterioration in the quality of the Ombudsman’s investigations over the last few years “in terms of the detail and analysis provided in the report and because there are often long delays that did not happen in the past.”


* Investigating clinical incidents in the NHS. Public Administration - Sixth Report

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