On 27 March 2015, the House of Commons Public Administration Select Committee published a report which recommended the establishment of an independent national body to investigate clinical incidents. This article summarises the context and the key conclusions.
Whilst the report accepted that there are already many initiatives in place addressing complaint investigations and promoting patient safety, it was thought that the processes for investigating and learning from incidents was too long and the process fragmented.
Despite the large number of organisations involved in investigating complaints, it was observed that none currently exist to improve them, and there is no accountability for their quality at a national level. As a consequence of inadequate processes many patients feel that litigation is their only recourse.
Summary of recommendations
As a result of its inquiry, the Select Committee has made the following recommendations:
- Establish a national independent patient safety investigation body. Dr Mike Durkin of NHS England has been invited to present specific proposals. The key criteria for this body are confidentiality, independence, transparency and accountability.
- Independent Medical Examiners, as provided for in the Coroners and Justice Act 2009, should be appointed for every clinical commissioning group to examine hospital deaths, to keep families of deceased relatives informed, and to alert the coroner to cases of concern. In time, such examiners should refer cases for investigation to the inquiry’s proposed new body.
- Educators, professional bodies and Royal Colleges should ensure that human factors and incident analysis modules are introduced as part of the training of healthcare professionals, with regular tutorials involving role play to increase understanding of how human factors can affect patient safety.
- There should be the development of a body of professionally qualified administrative and investigative staff who, over time, will be able to provide a substantial infrastructure in support of all investigation of clinical incidents. There should be formal examinations and qualifications similar to those formerly made by the Institute of Health Service Administration and the Association of Medical Records Officers.
- It has been recommended that the National Audit Office assist with an inquiry on the value for money of the Parliamentary and Health Service Ombudsman.
The aim of these recommendations is undoubtedly laudable. The reduction of adverse clinical incidents through learning from complaints must be an absolute priority, primarily in terms of patient safety, but also as a means of reducing the burden of litigation on the NHS.
It is undoubtedly correct that patients and NHS staff deserve to have untoward clinical incidents investigated swiftly, so that facts and evidence are established without the need to find blame, and regardless of whether a complaint has been raised. This will require strengthened investigative capacity locally, supported by a new, single, independent and accountable investigative body to provide national leadership. Of course, there will be a substantial issue relating to resource/funding and it remains to be seen whether and to what extent these recommendations will be implemented.