Headline figures and insight
The evidence that we collated is attached to this report in annexes B to E. This shows variation in the quality of investigations of patient safety incidents, and provides comprehensive evidence about what is going wrong in the system. This evidence is summarised here.
| Insight | Evidence | Our recommendation |
|---|---|---|
| The process of investigating as it stands is not consistent, reliable, or good enough. | 40% of investigations were not adequate to find out what had happened. 19% of investigations had relevant evidence (medical records, statements and interviews) missing when they were conducted. Trusts did not find failings in 73% of cases in which we found them. Trusts did not find out why things went wrong in 36% of cases where they found failings. |
To support all investigations to be carried out to a consistent and high quality, IPSIS should develop and champion broad principles of a good investigation. The emphasis should be on building capability and capacity at a local level whilst also allowing for flexibility and proportionality. |
| Serious incidents are not being reliably identified by trusts, and there exists wide variation between trusts, and within trusts, in terms of how patient safety incidents are investigated. | Out of the 150 cases we reviewed, 28 were judged by us to be serious enough to lead to serious incidents, but only 8 were reported as such. We found that identification often relied on either clinicians to spot an incident or on a central risk team flagging incidents. | |
| There is a lack of shared investigatory principles - how a case is investigated depends on the individual investigator. | There is no national guidance on patient safety incident investigations that sets out who should investigate and how independent they should be, level of training required, requirements for evidence needed, quality assurance, and general outcomes for good investigations. | To support all investigations to be carried out to a consistent and high quality, IPSIS should develop and champion broad principles of a good investigation. The emphasis should be on building capability and capacity at a local level whilst also allowing for flexibility and proportionality. |
| Poor quality investigations only increase the distress to the person who is complaining and their families. | In almost a fifth of investigations medical records, statements and interviews were missing, making it difficult for trusts to arrive at what went wrong and why. In 41% of cases inadequate explanations were given to complainants for what went wrong and why. |
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| Staff do not feel adequately supported in their investigatory role. | There is no national, accredited training programme to support investigators and/or complaints staff in their role. During our visits to trusts, staff cited a lack of respect, not being provided with protected time to investigate, and the lack of an open and honest culture as barriers to getting to the heart of why something has happened. There is inequity in terms of who can lead different types of investigations. We found serious incident investigations would often be led by a named investigator with training; all other investigations not meeting serious incident criteria could be led by an 'appropriate' |
IPSIS and NHS England should consider how the role of NHS complaints managers and investigators can be better recognised, valued and supported. This includes developing a national accredited training programme. Trusts should demonstrate to their boards they have clear objectives, both for their organisations and their staff, to be open and honest, learn from investigations, and resolve complaints. Boards should be using My Expectations to assess to what extent local complaints services are meeting the needs of people who use the service. |
| There are missed opportunities to learn | 25% of complaints managers were unsure that sufficient processes existed to prevent a recurrence of an incident. A further 10% of complaints managers believed sufficient processes were not in place. |
PSIS should work with others to lead, inspire and share learning from its own investigations in order to improve the capability of the local NHS. This includes demonstrating to organisations how they can take what they have learned from one investigation and apply it not just across divisions within a hospital, but across organisations too. The Department of Health and NHS England should work with IPSIS to make clear who has accountability for conducting quality NHS investigations at a national and local level. The different roles of providers, commissioners, regulators including NHS improvement, should be clearly outlined. |