What needs to change?
In April 2016, a new Independent Patient Safety Investigation Service (IPSIS) will be established. Through a combination of exemplary practice and structured support to others, IPSIS has the opportunity to make a decisive difference to how the NHS improves the way it investigates in the future.
We therefore call upon IPSIS and the NHS more broadly, to consider how the following recommendations can be implemented:
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IPSIS and NHS England should consider how the role of NHS complaints managers and investigators can be better recognised, valued and supported. This includes working with others to develop a national accredited training programme.
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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.
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IPSIS 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.
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Trusts should demonstrate to their boards that 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.
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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 organisations that provide care, commissioners, regulators including NHS Improvement, should be clearly outlined.
We believe that taken together, these changes will result in tangible improvements to the quality of local investigations.'
We believe that taken together, these changes will result in tangible improvements to the quality of local investigations. Although our report is a snapshot in time, it raises doubts over the ability of trusts to reliably identify when something has gone seriously wrong and why. Without this capability, trusts will continue to miss opportunities to learn and make service improvements.
As the stories in our report highlight, this is leading to tragic consequences for the people and families who are directly affected, and raises questions about whether the same preventable mistakes will not be repeated. There is some way to go before the NHS can be confident in the quality of local NHS investigations.
We look forward to playing our part in supporting improvements. As a first step, we will commit to disseminating our findings and will be sending copies of this report to the boards of each NHS trust across England.