Follow-up to PHSO report 'Learning from Mistakes' inquiry

In July 2016, the Public Administration and Constitutional Affairs Committee (PACAC)

received a report from the Parliamentary and Health Service Ombudsman (PHSO), Learning from Mistakes: An investigation report by the Parliamentary and Health Service Ombudsman into how the NHS failed to properly investigate the death of a three-year old child. This report is the PHSO’s second report into the tragic death of Sam Morrish, a three year old child whose death from sepsis was found to have been avoidable. The second PHSO report highlights systemic problems with clinical incident investigations in the NHS in England, where it found that a fear of blame inhibits open investigations, learning, and improvement.

Our further report corroborates these findings. The Department of Health, NHS Improvement, and Care Quality Commission all acknowledged the need for the investigative culture to be transformed into one in which open-minded, learning-focused investigations can routinely take place. However, despite repeated reports, both from PHSO and from PACAC, highlighting this as the critical issue facing complaint handling and clinical incident investigations in the NHS in England, there is precious little evidence that the NHS in England is learning. We found that, while a number of initiatives exist to improve the health service’s investigative culture, there was also a distinct lack of coordination and accountability for how these initiatives might coalesce.

PACAC concludes that there is an acute need for the Department of Health to step up and integrate these initiatives into a coordinated long term strategy that will meet the Secretary of State for Health’s ambition of turning the NHS in England into a learning organisation. As this report shows, it is critical that this strategy includes a clear plan for building up local investigative capability, because this is where the vast majority of investigations will continue to take place. Ministerial responsibility for clinical incident investigations in the NHS in England is diffused. PACAC therefore recommends that the Secretary of State for Health should be accountable to Parliament for delivering the coordinated implementation of the shift towards a learning culture in the NHS in England.

As part of our inquiry, we also considered the impact the new Healthcare Safety Investigation Branch (HSIB) will have on resolving some of the issues outlined in this report. The Government has accepted PACAC’s predecessor Committee PASC’s recommendation from March 2015 to instigate such a body. HSIB will conduct clinical investigations in a ‘safe space’ where people directly involved in the most serious clinical incidents can speak honestly and openly in the interests of learning. PACAC believes HSIB should become a key player in addressing the NHS in England’s blame culture.

However, HSIB is being asked to begin operations without the necessary legislation to secure its independence and the ‘safe space’ for its investigations. PACAC reiterates in this report that this is not acceptable. There is a real risk HSIB will start off on the wrong foot, without a distinctive identity and role within the investigative landscape.

It will not therefore have the intended impact of developing a learning culture in the health system.