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And the DoH wonder why there is a rise in adverse incidents and costs…

News | Fri 11th Dec, 2015

A very recent review (published on 8th December 2015) into the quality of English NHS complaints investigations by the Health Service Ombudsman where serious or avoidable harm has been alleged has led to a number of shocking findings that:

  •  40% of investigations were not adequate to find out what happened.
  •  Not only were trusts not identifying failings, they were also not finding out why the failings happened in the first place.
  •  Trusts rusts did not find failings in as many as 73% of cases in which the Ombudsman had found failings, and
  •  In over a third of cases where failings were found, trusts did not find out why something went wrong.

All of this is in marked contrast to the perception of 91% of NHS complaints managers who were confident an investigation could find out what had gone wrong.

In this very revealing review the Ombudsman looked mostly at incidents of avoidable harm classed as patient safety incidents and in which minor or moderate harm has occurred but also (more) serious incidents (defined as incidents resulting in “unexpected or avoidable death, unexpected or avoidable injury resulting in serious harm – including those where the injury required treatment to prevent death or serious harm, abuse.”).

150 NHS complaints investigations where avoidable harm or death was alleged were investigated. The Ombudsman was keen to learn about the current quality of complaints investigations and whether NHS investigations ever get to the root cause.  Six different trusts were looked at and over 170 NHS complaints managers were surveyed to provide additional insight into the issues.

It was found that serious incidents were not being reliably identified by trusts. 28 of the cases looked at were judged to be serious enough to justify a serious incident investigation, but only 8 had been treated as such by the NHS.

Moreover wide variation between and within trusts in terms of how patient safety incidents were investigated were found. Even more worrying, there was a distinct absence of shared investigatory principles. How a case is investigated appeared to be subject to an individual investigator.

The Ombudsman is understandably concerned that there is still no national guidance for patient safety incident investigations. It was perturbed that medical records, statements and interviews were missing from almost a fifth of the investigations making it even harder for trusts to arrive at what went wrong and why. The results showed that in as many as 41% of cases, complainants were given inadequate explanations for what went wrong and why.

Inadequate investigation is often the seed for a subsequent clinical negligence claim. Practitioners in this area often hear clients complain bitterly about their experience of the complaints process. It is hardly surprising that when mistakes are poorly investigated the patient sometimes feels compelled to seek legal advice.  It is an all too common experience for practitioners for liability to be continued to be denied until the eleventh hour in clinical negligence cases. This inevitably leads to massively increased costs, all of which must be borne by the NHS and ultimately not spent on better patient care. 

The report really underlines what claimant clinical negligence lawyers have long thought.  Not only are adverse events on the rise, they are then simply not investigated properly. What is surprising is that this investigation inadequacy occurs in so many cases. 

This is all the more poignant now.  It seems not only are the vast majority of patients singularly failed when their adverse incident is then investigated, the Department of Health now wants to hamper the patient’s lawyer’s ability to investigate (this time properly) by fixing the fee it has to pay when negligence is (eventually) conceded or won. This just cannot be right.


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