Learning from mistakes

Chapter 4: What we have learned from the Morrish family’s complaints

  1. 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.

Our role

  1. We recognise that when we received their first complaint about Sam's care we played a limited role in developing and using the insight from our casework to help others improve public services. Developing insight from complaints has been a key part of our strategy since 2013 and our approach has developed considerably since Mr and Mrs Morrish first came to us. We want to continue to use our insight to help increase the capabilities of those who handle complaints in public services and to support Parliament in holding public services to account.
  2. We now work to generate insight into poor complaint handling and learning from complaints, to help others develop solutions. This report is part of that activity and is one of three ways in which we are taking this work forward.

    Thematic reports

    We have increased the number of reports published on big and repeated mistakes. In doing so we have been able to show what other organisations in the wider NHS can learn from our findings in areas such as Midwifery Regulation, Sepsis, and the quality of local NHS complaint investigations about potential avoidable harm or death. These reports have supported the Public Administration and Constitutional Affairs Committee in their scrutiny of government learning from complaints. Our work on the quality of local investigations contributed to the committee's recommendations on both the establishment of the new Health Safety Investigation Branch (HSIB) and on improving local competence to investigate incidents such as the death of Sam Morrish.

    Individual cases

    We have changed the way that we investigate the small number of cases each year where we think we may find evidence that can contribute to wider learning across the NHS. Those investigations are now being undertaken by a small team with specific family liaison points and an assumption that interviews are completed. This second investigation for the Morrish family is one of those cases and the insight for the NHS as a whole is brought together in chapter 1 of this report.

    Recommendations to put things right

    If we see flaws in an organisation's investigation we will make recommendations for remedy that include the local NHS organisations revisiting the case to conduct a more thorough investigation. This would include using investigation methods that enable them to establish both what happened and why so that the findings can be used to learn and improve patient safety.

  3. We recognise the mismatch between people's understanding and expectation of our role and the reality. Last year we began work to articulate and communicate our role more clearly to the public in all our communications, including when we are looking into a case.

Our service

  1. We have seen how, in Mr and Mrs Morrish's case, our own methods of investigating and our interactions with the family mirrored some of what they experienced locally. Senior members of our team met with Sue and Scott Morrish after our first investigation, and apologised that we had not got it right for them in some aspects of our service. We have worked with them to understand their concerns in detail so that we can continue to learn and improve our service.
  2. The feedback the family gave us about our first investigation fit broadly into three areas. They were unhappy about the scope of our investigation and the method we used to conduct it, they said they were unhappy that we did not keep them informed, and they had concerns about the service in general that we provided, for example, the time taken to complete our investigation.

Scope and method

  1. The family said we did not listen carefully enough to what they wanted as an outcome from their first complaint: we focused on determining if there was service failure and whether or not their son's death had been avoidable. When we complete an investigation we consider what happened and what should have happened, and whether the gap in between the two is great enough for us to find fault with the organisation's actions. If we find that it is, then we uphold the complaint. However, they hoped our investigation could find out why the local services failed to conclude that Sam's death was avoidable, and what they could learn from this in the future, particularly for NHS incident investigations. This second investigation used a different method (including interviews) so to increase understanding of how and why things happened not just what happened.
  2. The family said our method was not transparent and this meant they could not check if it was going to deliver what they actually wanted from the investigation. They also said that our methodology was not adequate for achieving answers to all of the questions they had. In the end there was a mismatch between our method to establish what happened and their desire for local and system wide understanding of why Sam died and why the local organisations failed to identify their failures, in order to learn and improve patient safety. We need to do more to clearly explain the methods we use.
  3. The family also had concerns that, during our first investigation, documents we sent them contained factual inaccuracies and speculation. In complex cases in particular, we can do more to share and check the facts with all parties involved at an earlier stage in the investigation process. We need to separate clearly in our reports the facts of the individual cases from our findings. We also need to be clear with the parties that one of the key reasons we share our reports in draft with the parties involved is to ensure the accuracy of the facts.

Providing a good service

  1. The family told us they felt they had to continuously contact us to find out what was happening with their complaint. They also said that it felt as though we were 'managing' their contact with us, and that we seemed to view their contact as a hindrance rather than a help.
  2. We must be clear about when and how we will contact the parties involved.
  3. One of the family's key concerns was the time we took to complete our investigation – from April 2012 when we first received the complaint, to June 2014 when we finalised our report.
  4. We must be clear that the staff conducting the first investigation followed our methods and service standards at the time. It was our corporate standards that needed to change.


  1. Importantly for the purpose of this report we have tried to follow the three key elements of NHS accountability outlined in chapter 1 of this report in describing what we have done to improve our service:
    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 families with a full 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

i Listening to, and understanding, feedback

  1. The family's criticism of us when we completed our first investigation into their case was one of the triggers to change our own processes. We have listened to the feedback from them, and others, who have brought their complaints to us for a final decision as well as listening to the views of staff in the organisations we investigate. As a result we have developed new quality standards with people who use our service which will be launched in July 2016. 
  2. It will take us time to fully meet those standards. We also know from the experience of ombudsman services (across the UK and internationally) that complainants' acceptance of our service and decisions are linked to whether they view the outcome of the investigation favourably. However, we like any organisation, we will sometimes make mistakes and have processes in place to listen to feedback and concerns and take action to put matters right if we have made an error.
  3. The four things that people say give them most confidence in our decisions and service are:
    • to understand our role, what we can and cannot do and to be kept informed;
    • a robust, impartial and transparent process of looking into their complaint starting with listening to what people think the service failure is, and the outcome they are seeking by bringing their complaint to us;
    • to receive a service which is accessible, treats people with respect, is completed as quickly as possible and looks after their personal and confidential information; and
    • to be able to see how we are doing against these expectations

ii Learning and action to improve our service

  1. We have used what we have learnt from this case to feed into our greater understanding of what people want and expect from our service. Our new quality standards include new expectations for:
    1. communicating with complainants and organisations we investigate;
    2. the way we listen to complainants and feedback the scope we intend to investigate;
    3. how we provide an investigation plan for each case and explain how long that case is expected to take;
    4. conducting interviews in serious cases where other evidence, for example medical records, alone will not give a complete picture of what happened, and enabling us to weigh up evidence from all parties involved; and
    5. delivering an investigation as quickly as possible.
  2. We recognise that there is still much to do and we have work planned to help us:
    1. listen more to what people want from a complaint in order to help us make sure we investigate what really matters to people;
    2. continue to improve our communication with both complainants and the organisations we investigate; and
    3. continue to improve how we explain our decisions and how we have considered the evidence that we used to reach them.

iii Evidence and impact of changes

  1. We will continue to collect feedback from people who use our service, use quality checks to measure compliance with our new standards and management information on aspects such as how long we take to conclude investigations.
  2. We will publish that information online from the end of 2016 along with information about what we plan to do next to continue to improve our service.