• ‘Culture of secrecy’ blocks NHS staff learning from mistakes, warns watchdog

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  • 8 Dec 2015
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Ombudsman finds complaints against NHS employees are not investigated adequately

Staff are not empowered to investigate NHS failures and are blighted by a culture of secrecy, according to the NHS watchdog, which has found that 40 per cent of NHS investigations are inadequate.

Ahead of the launch of the newly formed Independent Patient Safety Investigation Service (IPSIS), which operates from next April, the Parliamentary and Health Service Ombudsman has released a damning report into NHS complaint investigations.

The report found that trusts were not identifying failings and were not finding out why they happened in the first place. Trusts missed failings in 73 per cent of cases where the Ombudsman found them.

A huge disconnect was also highlighted between the reality of the situation, as outlined above, and the perception of NHS complaints managers – with 91 per cent of them saying they were confident an investigation would find out what was wrong.

The result of all this has been a ‘stonewalling’ effect from the NHS on family and friends of patients affected as well as a lost opportunity for improvements.

Some 41 per cent of complainants were given inadequate explanations for what went wrong and why, according to the Ombudsman.

The report argued: “Organisations that provide care should not lose sight that it is patients, carers and families who are often at the heart of these investigations. They need to be involved in a meaningful way if investigations are to answer their questions. All of this has a huge impact on patients and families at the centre of any investigation.”

It also highlighted that in almost a fifth of investigations medical records, statements and interviews were missing. A huge problem – which presumably the new IPSIS will work to resolve – is a lack of structure, training and support around investigations. One example highlighted was the case of a baby who suffered brain damage after a blood transfusion, the investigation was carried out by a close colleague of the paediatrician in charge that day.

Contributing to the problem is also a lack of a national accredited training programme to support investigators or complaints staff.

Barriers, reported to the Ombudsman, on conducting thorough investigations included: cultural issues; lack of respect; not having protected time to investigate; and a lack of an open and honest culture despite the introduction of the duty of candour in November last year – designed to improve openness and transparency.

There is inequality in terms of who leads types of investigations with ‘serious incidents’ led by trained, named investigators and other events led by an ‘appropriate person’.

The report found: “Ultimately, staff need to be equipped and empowered to carry out investigations otherwise trusts risk adding to the distress felt by individuals and missing opportunities to make essential service improvements as the following case illustrates.”

These all resulted in lost learning opportunities with 25 per cent of complaints managers unsure that sufficient changes had been applied to prevent an incident from occurring again with a further 10 per cent going so far as to say that sufficient processes were not in place.

Authors of the report stated: “Learning from investigations appears to be trapped in high level meetings; and learning across organisations often relies on goodwill and personalities rather than any established processes or mechanisms. Our advisory group reported that cross organisational learning tends to be led by the willing few rather than something that is a widespread practice across the NHS.”

The Ombudsman report pointed out that there was no national guidance for patient safety incident investigations. It argued that such a protocol would need to: make clear who should investigate and how independent of events they should be; set a level of training; set broad requirements for specific evidence needed; outline how to ensure independent quality assurance; and set general outcomes that ought to be achieved.

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Comments (3)
  • It rather begs the question as to what the Ombudsman, watchdog does other than watch and report bad practice. Why has this been allowed to continue year after year? Now the Ombudsman is telling IPSIS how to do its job when her own organisation has been shown to fail the public on numerous occasions. Pot, kettle, black. phsothefacts.com

  • The following part of the CIPD account caught my eye: "There is inequality in terms of who leads types of investigations with ‘serious incidents’ led by trained, named investigators and other events led by an ‘appropriate person’."

    Having more senior and experienced staff look at the most serious problems seems entirely sensible to me, not "inequality", would you have them looked at by the least experienced people?

    The accusatory tone is also seen in the sentence about a complaint "being carried out by a close colleague". This suggests that a complaint investigation is not a "learning" experience as stated in the article but a trial. Who, apart from another specialist (Paediatrician in this case) would have the expertise to understand the medical action taken. Should all investigations be carried out by specialists from another hospital? Or should colleagues be distant from each other? I understand the point being made, it is the tone I find worrying.

    There is so much to learn from complaints, they form a vital link in designing training for example, but if NHS culture is to become less defensive then staff must be convinced that they are safe to take part and will benefit. The tone of this article simply reinforces that they are not. Reading, even in the broadsheets, the treatment of NHS personnel who make errors it's no wonder staff are in fear for their careers.

  • It's about time there was a standard for people investigating serious complaints, or indeed grievance and disciplinary matters. I just hope that IPSIS sets those standards at a sufficiently high level. That way, people volunteering for the role, or taking on the job of investigator, know what is required of them and know if they are up to the job. It's unfair and unreasonable for all concerned, including the investigator, if standards are set low. I'll watch this space with interest