PASC launches a new inquiry into how incidents of clinical failure in the NHS are investigated – and how subsequent complaints are handled. The Committee is considering ways that untoward clinical incidents could be 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. It is hoped that this work will reduce the need for complaints to go to the Parliamentary and Health Services Ombudsman (PHSO), whose main role relates to administrative and service failures in the NHS in England.
The inquiry aims to
- examine the effectiveness of existing approaches to investigating and addressing systemic safety issues currently present within the NHS
- explore the relative benefits that a new clinical accident investigation body might bring to this area and how analysis of complaints could inform its work
- consider models of best practice within other sectors and examine their transferability to the healthcare sector; and to
- explore the role that the PHSO might play in the functioning of any new accident investigation body
PASC would like to hear views on
- The effectiveness of the NHS’s current approach to investigating and addressing untoward medical incidents.
- How lessons about best practice, procedures and human factors should be learned and disseminated.
- The value that a new, single, clinical accident investigation branch of the Department of Health would bring to the healthcare sector and how this could improve the complaints process.
- The current capacity of the PHSO to manage and investigate complaints relating to clinical incidents, and their ability to analyse and assess medical evidence.
- The impact that Department of Transport accident investigation branches have had in the transport sector and the lessons that have been learnt from the establishment and use of such bodies, in the UK and in healthcare systems in other countries.
- How any such body within the healthcare sector would support the work of PHSO.
- The legal drivers behind increased challenges associated with the issue of medical liability, and the failure to address clinical incidents and complaints.
Bernard Jenkin MP, Chair of the Committee, said
"It is very unfortunate that the way clinical failures – which can be a tragedy for a person and their loved ones – are handled by the NHS and its watchdogs does not seem to foster positive outcomes or learning from mistakes that have been made. There seems to be a culture of blame and of responding only to complaints, rather than an environment where clinicians can come forward and lay out the facts of things that have gone wrong, or express concerns, so that they can be investigated and lead to improvements. Right now the only outcomes after clinical failings seem to be another excoriating report by a health watchdog, litigation or the passing of badly handled complaints further up the chain to adjudicators of last resort like the PHSO, which reports to Parliament through PASC. These outcomes may be the result of ‘starting from the wrong place’. We would like to examine the possibilities of new ways of reporting and investigating clinical failures that could being about positive outcomes and change at a much earlier stage. We are interested in the experience in other countries, particularly in New Zealand, which drew the support of a 2009 Health Select Committee Report on Patient Safety."
The Committee would also welcome views on any other matters that may be relevant to this inquiry. Please do not feel obliged to respond to all of the questions if you have a specific interest.
Work in this area has been prompted by public debate and the recent publication of an article in the Journal of the Royal Society of Medicine by Carl Macrae (Centre for Patient Safety and Service Quality, Imperial College London) and Charles Vincent (Department of Experimental Psychology, University of Oxford). This article compares accident investigation within the healthcare sector to that within air, rail and maritime transport. It argues that whilst these industries are "served by an independent and permanently staffed organisation that is explicitly charged with investigating serious safety risks and major failures", no similarly consistent approach exists within the NHS:
"These independent investigators are responsible for coordinating all major safety investigations in their industry. They have a remit to investigate the entire industrial complex, encompassing design of equipment, the culture and practices of delivery organisations such as airlines or shipping companies, and the role of regulators and government. Their independence is essential to their effectiveness. It allows them to routinely investigate the full range of factors that underlie major failures, irrespective of whether those are rooted in the behaviour of an individual professional or the design of an entire regulatory system."
Macrae and Vincent suggest that by applying such learnings the NHS could develop an investigation agency for healthcare which would be:
- Independent and impartial. No executive, regulatory, commissioning or performance management functions
- Transparent. Clear, timely, open communication of findings of investigations, recommendations and monitoring of implementation
- Established as permanent body able to investigate and follow up recommendations over years
- Collaborative and cooperative. Working in partnership with those being investigated
- Authority to access all sites, organisations, staff and information across the healthcare system
- Non-punitive. Separated from assignment of blame or liability and legally protected
PHSO investigates complaints where individuals have been treated unfairly or have received poor service from government departments, other public organisations and the NHS in England. The service that PHSO provides is governed by law, free to use, open to everyone and completely independent.
PASC scrutinises the reports of the Parliamentary and Health Service Ombudsman. PASC monitors complaints about the Ombudsman as a way of examining the work of her office and identifying systemic problems, but does not consider individual cases.
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