Learning from mistakes

Chapter 1: Summary and insight


Mr and Mrs Morrish complained to us in 2012 about the care and treatment provided to their son Sam by a GP Surgery, NHS Direct, Devon Doctors and an NHS Trust. They also complained about how those organisations, and the local Primary Care Trust, investigated what happened to Sam.

In our first investigation report we upheld Mr and Mrs Morrish's complaints. We found failures on the part of every organisation involved in the care that they provided to the family. We found that, were it not for the failures we identified, Sam would have lived. We also found failures in the way that the organisations involved dealt with Mr and Mrs Morrish's complaints about the care provided to Sam.

Mr and Mrs Morrish welcomed our findings, however, they had also always wanted us to ask why the failings had occurred in Sam's treatment, and why the subsequent investigations conducted locally had failed to conclude that Sam's death was avoidable. As a result, we agreed to undertake a second investigation in order to establish 'how' and 'why' the organisations involved failed to identify that Sam's death was avoidable and to explore the lessons for the wider NHS.

We also agreed to look at the mismatch between the family's expectations of us and what we delivered in our first investigation. We have considered how the family's experience of our service has impacted on how we go about our work and how our work contributes to an increase in wider learning in the NHS.

Mr and Mrs Morrish have pursued their complaints for so long because they want NHS organisations to understand when mistakes are made in order to learn from them and improve. This learning depends upon the NHS recognising when an incident of potentially avoidable harm has occurred and having the right skills and experience to investigate it robustly.

We know the NHS currently has a significant problem with the quality of investigations into avoidable harm and there have been a number of published reports on the subject recently including:

  • NHS England's recent review of maternity services which found a lack of consistency in the standard of local investigations.
  • A 2015 study by the Royal College of Obstetricians and Gynaecologists which found that over a quarter of investigations into problems during labour were of poor quality.
  • The review of unexpected deaths at Southern Health Trust.1
  • Our own report, published in December 2015, on the quality of NHS investigations found that 40% of investigations were not adequate at finding out what had happened.
  • CQC briefing: Learning from serious incidents in NHS acute hospitals identified five significant areas for improvement2.

The Secretary of State for Health has recognised that NHS hospitals need 'to feel interested in what happened, and should set up structures where independent investigations can be made into any avoidable harm'.

Public trust depends on accountability, not blame

Public trust and confidence in services depends in part on accountability for improvements in service and safety that have resulted from learning.

We think, in relation to complaints of potential avoidable harm, demonstrating accountability includes three vital steps:

  1. Being willing to accept your own initial view might not be right and to ask open questions as an individual and as an organisation about what happened. In other words to do a proper investigation that involves all staff who provided diagnosis, care and treatment and the patient or their family. Providing staff and patients (and their families) with an honest explanation of what happened and why;
  2. Learning from the investigation and taking steps to improve the service;
  3. In the longer term providing evidence of performance against that expected as a result of the improvements being made – being able to assure the service leaders and the public that the service has improved.

If a service or group of services cannot pass the first test, as in this case, then it is impossible to learn, take action and measure performance improvements as a result. Instilling a willingness to ask questions and be curious as to other potential explanations for potential serious incidents should be the aim to help families, staff and services when such things happen.

The family who brought this complaint to us have told us that they have pursued their complaints for over 5 years to encourage NHS organisations to get the first step right so that they can learn and improve safety when mistakes are acknowledged and learnt from. They want staff to understand what happened and why and be able to learn so that services can be made safer. They want the learning from this case to be used by other health service providers and the NHS as a whole as a catalyst for wider improvement.

Culture and competence

This case, like so many others, shows that organisations were not competent in the way they investigated this serious complaint and that this incompetence went unchallenged. Why? There is plenty of evidence and insight across the NHS that fear of blame drives defensive responses. This may have been the case here.

For NHS organisations and staff to be confident to get to the bottom of what happened requires the building of a culture of positive accountability to find out and understand if something did go wrong and where it did to determine whether human error, system failure or a combination of the two lay behind mistakes. There is a need to work towards ending the fear of punitive responses and reputational damage being an immediate consequence of openly accepting that an error may have occurred.

This need is well articulated by one of those tasked by the NHS to investigate the Morrish family's concerns – a Chief Executive of a neighbouring NHS Trust. When we interviewed the Chief Executive he said:

'The "why" question I wish to raise is in relation to our investigation processes in complex cases, when a series of things seems to have gone wrong.

'Why do we not have coherent and consistent investigation processes? In this Trust we have introduced a "Patient Safety Team". Its role is to investigate serious incidents quickly, consistently and thoroughly, involving family, carers, staff, etc. It is still in its infancy but is based on the notion of an air accident investigation team.

'In the case of Sam, this was a complex case and arguably a preventable death. It was immediately evident that there had been multiple factors relating to Sam's illness and ultimate death. In such a serious case, where learning is critical in trying to prevent future deaths of this nature, I believe we should have expert investigation teams that can investigate thoroughly, rapidly, consistently and without prejudice. Not seeking to purchase blame but to understand what went wrong and to determine whether human error, system failure or a combination of the two. A series of clear actions and recommendations should be published and implemented.

'The current system, certainly in some parts of the NHS, relies on current staff who are not experienced in investigations to carry out what can be very complex investigations. I believe it is critical to ensure we have trained and experienced investigators working to consistently high standards to ensure learning and improvement, to give the public confidence in the thoroughness of investigation and to ensure changes are made as a result.

'If I was the Ombudsman or the Secretary of State, I would be asking why we do not have rapid, consistent and thorough investigations into cases as complex as Sam's.'

This shift towards a more positive culture will drive both the development and embedding of organisational competence to investigate, learn and improve and the confidence to challenge the lack of it.

Again, this is what the family say they want to see happen. They have been extraordinarily generous spirited and consistent in articulating the lack of psychological safety felt by staff when they fear or experience blame, or a lack of involvement or a lack of support to get things right. They view this as an injustice experienced by staff involved in serious incidents as well as families.

Below we describe the mistakes and missteps in the process of investigating the reasons for Sam Morrish's death and handling the resulting concerns of the family. We then describe some recommendations for the NHS which needs urgently to tackle both technical competence and culture.


Mr and Mrs Morrish complained that the NHS investigation review processes are not fit for purpose, believing that they are not sufficiently independent, inquisitive, open or transparent, properly focused on learning, or able to span organisational and hierarchical barriers, and that they exclude patients, their families, and junior staff in the process. In relation to the investigations undertaken after Sam's death, we agree.

We have upheld the complaints put to us by the family about every organisation that investigated aspects of Sam's care. We have found that those involved were not always suitably independent and that the organisations failed to co-ordinate and cooperate sufficiently with one another. We have identified a failure to obtain appropriate information, a lack of timely statements being taken as part of any formal process and a lack of appropriate (and in some cases any) involvement and communication with both the family and the staff.

The organisations made no clear attempt collectively to seek to identify lessons from this case. Without a proper investigation into the events that took place, involving the staff and the family, there was no possibility of learning (locally or nationally) or action being taken to avoid such incidents in the future. Had the investigations into Sam's death been proper at the start, it would not have been necessary for the family to pursue a complaint.

Mr and Mrs Morrish have asked us if we have found any evidence that the organisations tried to 'cover up' the failures in Sam's care. We have not found any such evidence. Rather, we believe a fundamental failure in this case was the organisations - in particular the Trust – total unwillingness to accept that no view other than their own was the right one. Those involved appeared to accept almost immediately the view that Sam's death was rare and unfortunate rather than being open to other possibilities and, in doing so, asking open questions as part of a proper investigation that involved staff and the family. This was coupled with a general failure to accept that the questions the family were asking might have been reasonable ones.

In particular, we note the PCT's role and the opportunity it had to look holistically at the failures of all organisations involved. We have found that the PCT failed to ensure that the organisations involved in Sam's care were aware of his death and the need to investigate it fully and appropriately. The organisations involved did not work together and undertake one effective investigation. We have found that this was, in part, down to the failure of the PCT to properly and effectively co-ordinate the investigations as recommended in such circumstances by the NHS complaints regulations.

Had the PCT acted properly, and considered clearly and effectively what the organisations had done compared to what they should have done, they would have identified at least some of the learning that we have identified in this (and our earlier) report. We note that some of the organisations involved were seemingly dependent on the PCT for information about the investigations and communication with the family. Although it is correct to say that the PCT had a key role in coordination and communication, we think it should have been clear to the other organisations involved that this process wasn't working for the family. In the absence of effective coordination by the PCT, the organisations involved should have done more to communicate properly and clearly with the family.

Most importantly for the family, the organisations involved locally made no clear attempt to seek continuous improvement and identify lessons from this case together.

Further detail on our findings is in chapter 3.

Our accountability

Following the publication of our first report and our decision to undertake a second investigation, we agreed to look at how we handled Mr and Mrs Morrish's first complaint so that we could learn from their experience and consider how that learning might inform our work in future. We are part way through a very significant modernisation of our service and so we have been able to build the learning from the family's feedback into that process. As such, the family's experience has fed into both our service improvements and how we have developed our role in order to maximise the insight from complaints and feed the learning back to service providers for improvement.

Further detail on our learning is in chapter 4.

Conclusion and recommendations

As we highlighted at the beginning of this chapter, the findings in this case are common. Many NHS providers and commissioners will identify with elements of our findings.


We concur with the five areas for improvement identified by the recent CQC Briefing: Learning from serious incidents in NHS acute hospitals3:

  1. Serious incidents that require full investigation should be prioritised and alternative methods for managing and learning from other types of incident should be developed.
  2. Patients and families should be routinely involved in investigations.
  3. Staff involved in the incident and investigation process should be engaged and supported.
  4. Using skilled analysis to move the focus of investigation from the acts or omissions of staff, to identifying the underlying causes of the incident.
  5. Using human factors principles to develop solutions that reduce the risk of the same incidents happening again.

There are also improvements to be made in communication, co-ordination and governance within and across organisations.

As we noted in our report into the quality of NHS complaints investigations where serious or avoidable harm has been alleged4 we recommend training and accrediting sufficient investigators to operate locally. We also believe there is a need for the role of NHS complaint managers and investigators to be better recognised, valued and supported.

We welcome the role that Healthcare Safety Investigation Branch (HSIB) will play in developing and promoting best practice to take this agenda forward.


The impact of actions to improve competence will be limited without a parallel focus locally and nationally on creating a just culture. Tackling the current defensive culture and fear of blame requires soul searching and bravery at every level from politicians to system leaders, organisational leaders, clinical leaders and front line staff.

The focus on a 'safe space' for the investigations of the new Healthcare Safety Investigation Branch (HSIB) is absolutely a step in the right direction. However, all but a very small number of investigations will continue to be conducted locally, just like this one. Now is the time for the NHS to build on the momentum started by the creation of HSIB and explore how it can give staff across the NHS the confidence to be open to exploring what happened so that, if mistakes were made, they can learn and improve safety for others in future.

We recommend that NHS system leaders (including NHS Improvement, NHS England, Department of Health and CQC) consider how they can provide collective and collaborative leadership to create a positive, non blame culture in which leaders and staff in every NHS organisation feel confident to openly investigate and report, learn and improve patient safety.

1  Mazars (2015) Independent review of deaths of people with a Learning Disability or Mental Health problem in contact with Southern Health NHS Foundation Trust April 2011 to March 2015

2 Care Quality Commission (2016) BRIEFING: Learning from serious incidents in NHS acute hospitals. A review of the quality of investigation reports. June 2016. 

3 Care Quality Commission (2016) BRIEFING: Learning from serious incidents in NHS acute hospitals. A review of the quality of investigation reports. June 2016.  

4 Parliamentary and Health Service Ombudsman, A review into the quality of NHS complaints investigations where serious or avoidable harm has been alleged, December 2015.