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Deaths and avoidable harm not properly investigated in hospitals

Health Ombudsman slams the way NHS handles complaints

Jo Carlowe

Tuesday, 08 December 2015

Families of patients involved in avoidable deaths are being left without answers as incidents of harm are not being properly investigated by hospitals in England. 

In a damning report, published today, the Parliamentary and Health Services Ombudsman (PHSO) concludes that nearly three quarters of hospital investigations into complaints about avoidable harm and death claimed there were no failings in the care given, despite PHSO investigations of the same incidents uncovering serious failings.

The report reveals that hospitals are not investigating serious incidents properly because they often do not gather enough evidence, use inconsistent methods and do not look at the evidence closely enough to find out what went wrong and why.

The PHSO launched the review because it found a wide variation in the quality of investigations carried out by the NHS into complaints about avoidable death and harm.

Among the shocking revelations, is the finding that more than half (52%) of the investigations about avoidable harm and death carried out by the NHS where a clinician reviewed what had happened, used a clinician who was not independent of the events complained about, the review uncovered.

The review was based on interviews with hospital staff, a survey of NHS complaint managers and a review of the unresolved NHS complaints brought to the Parliamentary and Health Service Ombudsman. It found that:

  • Nearly three quarters (73%) of cases where the Parliamentary and Health Service Ombudsman found clear failings, hospitals claimed in their earlier investigations of the same incident that they hadn't found any failings.
  • Hospitals failed to class more than two thirds (20 of 28) of avoidable harm cases as serious incidents, meaning that they were not properly investigated.
  • A fifth (19%) of NHS investigations were missing crucial evidence such as medical records, statements, and interviews.
  • More than a third (36%) of the NHS investigations which recorded failings did not find out why they had happened, despite more than 90% (91%) of NHS complaint managers claiming that they are confident they could find out answers.

Parliamentary and Health Service Ombudsman Julie Mellor said: “Parents and families are being met with a wall of silence from the NHS when they seek answers as to why their loved one died or was harmed.

“Our review found that NHS investigations into complaints about avoidable death and harm are simply not good enough. They are not consistent, reliable or transparent, which means that too many people are being forced to bring their complaint to us to get it resolved. 

“We want the NHS to introduce an accredited training programme for staff carrying out these investigations as well as guidance on how they should be done, so the public can be confident that when someone is needlessly harmed it has been thoroughly investigated and answers provided, so that action can be taken to prevent the same mistakes from happening again.”

The hospital visits and survey of NHS managers found that frontline staff do not understand the important of learning from investigations because discussions about what improvements should be made are trapped at meetings with senior managers, who then fail to discuss them with those who provide the care.

When ombudsman staff spoke to hospital staff, they did not find any consistency about the level of training of NHS investigators. Some hospitals had a list of trained investigators while others did not use trained investigators but said that incidents were investigated by “the appropriate person”. 

Complaints about potential avoidable death make up around 20% of the NHS complaints the Parliamentary and Health Service Ombudsman investigates. Since 1 January 2015 to 1 December 2015 it investigated 536 cases about potentially avoidable deaths and upheld around half of these, a total of 264. Overall for health cases it upholds around 40% of complaints.

Katherine Murphy, Chief Executive of the Patients Association, described today’s figures as “inexcusable” but “not surprising”.

“The Patients Association has known for many years that NHS investigations into patient complaints have not been good enough. Patients have been suffering in silence for too long.” 

Neil Churchill, NHS England’s Director for Improving Patient Experience, said: “When people make a complaint that they have been seriously harmed, they should expect it to be taken seriously and thoroughly investigated. The best way to improve care is to listen to what patients and their families tell us and learn from past experiences. Good quality, timely and consistent investigations are vital and the NHS continues to work hard to ensure patients feel confident raising issues or concerns.”


* A review into the quality of NHS complaints investigations where serious or avoidable harm has been alleged. Parliamentary and Health Service Ombudsman, 2015.

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