The House of Commons Select Committee recently recommended that a new investigatory body be set up
Earlier this year The House of Commons Public Administration Select Committee (PASC) called for a national body to be set up specifically to investigate medical accidents in England.
Their report states that “despite pockets of best practice, good intentions and strong leadership”, the current investigation of medical accidents and complaints process leaves much to be desired, “[falling] far short of what patients, their families, clinicians and NHS staff are entitled to expect”.
The PASC report came weeks after the inquiry into the Morecambe Bay NHS Trust which revealed a myriad of failings, including the revelation that 11 babies and one mother had died unnecessarily at Furness General Hospital, and that these deaths had not been investigated properly.
The report highlights how the MPs consider complaints have been dealt with in the past, with “denial, defensiveness and evasion”. Investigations are seen to be “too slow [and] substandard” often excluding patients, and the system is currently “unacceptably complicated” to the point of being unnavigable, with more than 70 bodies playing a role in the complaints and investigations procedure.
At present, responsibility for investigating patient safety is divided between the Parliamentary and Health Service Ombudsman and the Care Quality Commission at a national level, and on a local level, the NHS trusts themselves. The PASC report seeks to change that.
The proposed new system introduces a “new, permanent, simplified, functioning, trusted system” which promotes an “open and just culture”, with investigations carried out by trained and independent staff. There is to be no emphasis on blame, but on establishing the facts early in order to deal with the matter promptly, and to allow for lessons to be learned. In fact, it is suggested effective dealing with incidents may resolve an issue before a complaint is made at all.
This call for thoroughly investigating incidents seems to be a step in the right direction towards making the path to obtaining justice less fraught for those who have been subjected to clinical negligence. Similarly, early establishment of the facts could go some way towards helping patients and their families deal with and understand the traumatic experience they have gone through. From a clinical negligence perspective, the idea of an independent body seeking to investigate and clarify incidents of negligence and so create an NHS that is willing to learn and take responsibility for its actions is a welcome one - although whether it will be put into action remains to be seen: the Department of Health has said it will respond to the report “in due course”.