Follow-up to PHSO report on clinical investigations

In December 2015 the Parliamentary and Health Service Ombudsman (PHSO) published a Review into the quality of NHS complaints investigations where serious or avoidable harm has been alleged highlighting concerns about the ability of NHS organisations to conduct effective clinical investigations. Following a review of 150 NHS investigations in which avoidable harm or death had been alleged, PHSO found that “NHS Trusts are not always identifying patient safety incidents and are sometimes failing to recognise serious incidents” and that the quality of investigations is “inconsistent, often failing to get to the heart of what has gone wrong and to ensure lessons are learnt.”

The Public Administration and Constitutional Affairs Committee (PACAC)

subsequently conducted a short inquiry into the issues identified in the PHSO report.

This built on the work of PACAC’s predecessor committee, the Public Administration Select Committee (PASC), which recommended in March 2015 that the Government create an independent and transparent national clinical investigations function, modelled on the Air Accidents Investigation Branch, which would create a ‘safe space’

for people directly involved in the most serious patient safety incidents - as patients, clinicians, or family members - to speak honestly and openly in the interests of learning from mistakes. The Government subsequently accepted this recommendation in its July 2015 response Learning not Blaming and set up an Expert Advisory Group to produce more detailed proposals for the new Investigation Branch. The EAG’s final report was published on 12 May 2016.1 During the course of our inquiry both the Department of Health and NHS England responded positively and constructively to the PHSO’s report. Both acknowledged that NHS England currently lacks a broad and deep high quality clinical investigations capability and that it does not deal with complaints effectively. The establishment of a national clinical investigations function, the Healthcare Safety Investigation Branch (HSIB), is a critical step towards improving how NHS organisations handle clinical investigations, although its remit does not include complaints handling.

However, for HSIB to succeed it must be underpinned by primary legislation, providing for its independence and creating the crucial ‘safe space’ in which doctors and patients, as well as their families and carers, can provide full and candid contributions to patient safety investigations, without fear of punitive sanctions. HSIB must also take full responsibility for setting national standards and establishing appropriate accreditation and training for local investigators. This is essential if HSIB is to drive up the quality of clinical investigations at a local level, where, given its own limited capacity, the vast majority of investigations will continue to take place. The Committee’s recommendations on HSIB fit closely with those made by the EAG in its final report. There is a clear consensus that the Government must do more to ensure HSIB’s independence and effectiveness in reducing risks to patient safety, but there is still a long way to go to realise the Secretary of State for Health’s ambition of creating “the world’s largest learning organisation”.

1 Report of the Healthcare Safety Investigation Branch Expert Advisory Group (May 2016).