Clinical Advice Review: Final report and our response

Applying the appropriate range of methods when investigating the causes of poor care, and sharing learning


Sir Liam felt that PHSO’s current approach to investigation placed too much emphasis on the culpability of individual clinicians. He proposed:

  • the organisation should take a systems-based approach to investigations and caseworkers, should be trained in alternative investigative approaches such as human factors analysis.

The Independent Adviser also recommended that a new system of data and information should be created to enable PHSO to more easily identify serious cases and share learning on a more regular basis with NHS services. He noted that a “severity of potential harm” classification for all incoming complaints would also enable a more effective tailoring of investigative approaches.

The Review agreed that PHSO could do more to ensure consistent consideration of the full range of relevant factors when investigating clinical failings. It also agreed that there should be far greater transparency about where things have gone wrong, what recommendations have been made to remedy this and whether this has been accepted. The Review recommended that PHSO:

  • assess the benefits of supplementing its current investigative methods with additional approaches, learn from the work of other Ombuds and Regulators and identify options that could be built into PHSO’s service
  • ensure the matters highlighted by the Independent Adviser are given full consideration in PHSO’s existing work on risk profiling of cases and planned work to meet its strategic commitment to greater transparency.


The Review heard some concerns from both complainants and organisations in remit that inadequate consideration is given to wider potential evidence, including human and social factors, to balance against clinical factors when considering failures in care and treatment. This led some to question whether PHSO effectively identifies and escalates systemic issues.

Our response

In 2019/20 we will:

  • Review our risk profiling process to ensure it effectively captures “severity of potential harm”.
  • Based on this Review, identify any further activity that is needed to make sure we are both identifying appropriate insight to share with parliamentarians and policy makers and meeting the obligations around patient safety issues to which we are committed through our membership of the Emerging Concerns Protocol (this provides a mechanism for PHSO to share information and intelligence on potential risks to service users with health and social care regulators).
  • Begin work to engage with professional regulators and other Ombuds to identify additional approaches to investigation we might incorporate into our service and develop options for how we might achieve this.

In 2020/21 we will:

  • Set out any new approaches to investigation we decide to introduce into our service and how we plan to deliver these as part of our next corporate strategy.