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Select committee: Public Administration and Constitutional Affairs Committee

2nd Report - PHSO Report: missed opportunities: North Essex Partnership University NHS Foundation Trust

HC 31 Published 4 November 2019

Public Administration and Constitutional Affairs Committee Follow up to PHSO report ‘Missed Opportunities’ inquiry Report on parliament.uk ↗

Recommendations and conclusions 8

  1. 1
    The Committee notes with concern the significant body of evidence from the Care Quality Commission,... Conclusion · paragraph 24 Conclusion (the committee's words)
    The Committee notes with concern the significant body of evidence from the Care Quality Commission, the PHSO report and others that there is a need for significant improvements in the safety and quality of mental health provision. The Minister and the NHS should make this an urgent priority.
  2. 2
    In this context, we welcome the steps that the NHS and the Department of Health... Conclusion · paragraph 25 Conclusion (the committee's words)
    In this context, we welcome the steps that the NHS and the Department of Health and Social Care are taking to improve safety and the quality of mental health care provision. We agree with the recommendation of the Care Quality Commission that NHS England and NHS Improvement should ensure that the entire NHS workforce has a common understanding of patient safety and that patient safety should form part of ongoing mandatory training and be included as part of continuing professional development.
  3. 3
    The PHSO report powerfully demonstrates the need for effective leadership within the NHS. Recommendation · paragraph 35 Recommendation (the committee's words)
    The PHSO report powerfully demonstrates the need for effective leadership within the NHS. Good leadership is not just about taking action and giving clear direction. Good leaders also empower people to speak with candour, enable difficult conversations to take place, and hear uncomfortable truths, so that concerns and problems are addressed. Furthermore, mistakes and service failures must be acknowledged early. We welcome the Government’s plans to specifically cover plans for leadership in the NHS within the People Plan, to be published later this year. The Government should make clear however that ensuring effective leadership within an organisation is not simply a one-off event but rather is an iterative process of continuous improvement.
  4. 4
    Mental Health Trusts must be clear about their values and mission, and they need to... Conclusion · paragraph 44 Conclusion (the committee's words)
    Mental Health Trusts must be clear about their values and mission, and they need to reflect this in their culture. They must be clear that the term culture refers to the attitudes and behaviours which people in the organisation tend to adopt. Leadership must lead by example with the right attitudes and behaviour. There has to be open discussion when attitudes and behaviour is not consistent with the values of the Trust.
  5. 5
    We welcome the Minister’s commitment that the families affected will be fully involved in the... Conclusion · paragraph 47 Conclusion (the committee's words)
    We welcome the Minister’s commitment that the families affected will be fully involved in the NHS Improvement and NHS England investigation. As we have set out earlier in our report, the two tragic cases raised in the PHSO’s report were not the only complaints that have been made about the Trust. NHS England and NHS Improvement’s review should make sure that all families that have been affected by similar incidents to the ones detailed in the PHSO’s report are also fully involved in the investigation, if they would like to be.
  6. 6
    We welcome the inclusion of Health Service Safety Investigations Bill (HSSIB) in the Queen’s Speech,... Recommendation · paragraph 54 Recommendation (the committee's words)
    We welcome the inclusion of Health Service Safety Investigations Bill (HSSIB) in the Queen’s Speech, a piece of legislation that the Committee has strongly supported 20 Follow up on PHSO report: Missed opportunities for many years. In particular we believe that the introduction of the ‘safe space’ principle will facilitate more open investigations and proper learning to reduce repeated incidents. We recommend that the Bill be included in the Queen’s Speech following the upcoming General Election.
  7. 7
    It is vital that families can have confidence in clinical investigations. Conclusion · paragraph 55 Conclusion (the committee's words)
    It is vital that families can have confidence in clinical investigations. The lack of confidence expressed by witnesses to our inquiry is a cause of serious concern. While we have confidence that HSSIB’s investigations, once it is properly established will be effective in improving learning from incidents, NHS Trusts must also be capable of performing effective local investigations when incidents arise. The NHS should take steps to use HSSIB investigations to improve their own local investigations. For example, by learning from examples of best practice in clinical investigations.
  8. 8
    We reiterate our previous recommendation that there needs to be fundamental reform of the PHSO’s... Recommendation · paragraph 57 Recommendation (the committee's words)
    We reiterate our previous recommendation that there needs to be fundamental reform of the PHSO’s governance, which will require legislation. It was disappointing that such legislation was not included in the Queen’s Speech 2019 but the Government and Parliament must ensure that the Draft Public Service Ombudsman Bill is scrutinised by a Joint Committee of both Houses of Parliament as soon as possible.