Stephen Jones asks if a new Independent Patient Safety Investigation Service will improve the complaints system in the NHS.
Two reports this week have raised serious questions about the ability of the NHS to deal with complaints and investigate its own failings, with the result that important lessons from health care failings are not being learnt. An independent inquiry into Southern Health NHS Foundation Trust revealed that between April 2011 and March 2015 the Trust failed to properly investigate many unexpected deaths of patients with mental health problems or learning disabilities. When investigations were carried out they were often late, and of poor quality. Sadly, it does not appear that this report is addressing something unique to that Trust.
The report followed the publication earlier in the week of a separate review by the Parliamentary and Health Service Ombudsman (PHSO) into the quality of NHS complaints investigations where serious or avoidable harm has been alleged. The PHSO report casts doubt as to whether Trusts are really able to conduct effective investigations, finding that they sometimes fail to even recognise serious incidents. When investigations do happen, the quality is inconsistent, often failing to get to the heart of what has gone wrong and to ensure lessons are learnt.
The PHSO gathered evidence about the quality of NHS investigations through four strands of work: an initial review of 150 cases; a survey sent to 171 complaints managers in all acute trusts in England; visits to a number of acute trusts across the country; and then convening an advisory group to test its findings.
The PHSO concluded that the process of investigating is not consistent, reliable or good enough. 40% of investigations were not adequate to find out what had happened; 19% of investigations had relevant evidence (medical records, statements and interviews) missing when they were conducted; Trusts did not find failings in 73% of cases in which the review found them; and Trusts did not find out why things went wrong in 36% of cases where the review found failings.
Serious incidents are not being reliably identified by Trusts; only 8 of the 28 cases considered by the review to be serious enough to lead to a serious incident investigation had in fact been treated as such by the NHS.
The PHSO also noted that NHS staff do not feel adequately supported in their investigatory role and highlighted the lack of an open and honest culture despite the introduction of the duty of candour in November 2014. The upshot is that there are missed opportunities for learning.
The motivation of many who complain is to try to ensure that the same thing does not happen to somebody else. This is clearly not happening: the report notes that 25% of complaints managers were unsure that sufficient processes existed to prevent a recurrence of an incident, whilst a further 10% believed sufficient processes were not in place.
The impact of poor quality investigations results in missed opportunities to learn and make the relevant service improvements. As the PHSO review states, 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. The finding that in 41% of cases, complainants were given inadequate explanations for what went wrong and why is disturbing.
So, what can be done? In April 2016, a new Independent Patient Safety Investigation Service (IPSIS) will be established. The opportunity is there for IPSIS to change the way in which the NHS investigates in the future: let us hope that the lessons from these reports are learned and that IPSIS makes a fundamental difference.