Introduction
When things go wrong with NHS care, it can have devastating consequences for patients and their families. People want answers, to understand what happened and why, and to know that action is being taken to prevent the same thing happening again to others.
But our research has cast a question mark over the current ability of NHS organisations to conduct effective investigations where it is alleged that someone may have been harmed, or died, avoidably. We have found that NHS trusts are not always identifying patient safety incidents and are sometimes failing to recognise serious incidents. When investigations do happen, the quality is inconsistent, often failing to get to the heart of what has gone wrong and to ensure lessons are learnt.
As part of our review of the quality of NHS investigations, we asked: how successful are NHS organisations, particularly acute trusts, at determining what went wrong and why? Are lessons being learnt and applied, not just across departments but across organisations and localities? Is appropriate action being taken and if not, why not? What can be done to improve how local investigations are conducted and delivered so that more people are not subjected to the same errors time and time again?
This report explains the findings of our research, highlights the issues we have identified, and sets out the action we believe needs to be taken to improve the quality of NHS investigations.