27.03.15
MPs call for new independent patient safety investigation body
A national independent patient safety investigation body should be established as soon as possible, according to a group of cross-party MPs.
The Public Administration Select Committee has called on the incoming health secretary after the election to “act immediately” on the issue. In a new report it said that the service is needed because of the scale of problems in the NHS.
The MPs said the current patient safety system was "too complicated" and "took too long".
It follows health secretary Jeremy Hunt backing the establishment of an independent patient safety investigation unit to rapidly investigate serious medical incidents in response to the Morecambe Bay report.
Bernard Jenkin MP, chair of the committee, said: “Ever since the Mid Staffs hospital crisis and the Francis Report, it has been evident that the NHS has urgent need of a simpler and more trusted system for clinical incident investigation at both local and national level.
“This was again confirmed by the Kirkup report into the Morecombe Bay baby deaths. There needs to be investigative capacity so that facts and evidence can be established early, without the need to find blame, and regardless of whether a complaint has been raised.
“Our proposals for a new investigatory body will help transform the safety culture of the NHS and help to raise standards right across the NHS. This proposal is widely supported and it should be taken up early in the new Parliament.”
The committee report notes that more than 10,000 serious incidents are reported to NHS England annually. There were 338 recorded "never events" (such as wrong site surgery) in 2013-14 and NHS England received 174,872 written complaints.
It continues to list figures, with the NHS Litigation Authority’s latest estimate of clinical negligence liabilities at £26.1bn and the cost of the Francis Inquiry into the Mid Staffordshire NHS Foundation Trust being £13.6m.
The committee says that the huge numbers involved in the overall work of the NHS – 15.8 million admissions to hospitals and 19.2 million A&E attendances in England the year to November 2014 –put those figures in context. However, it continues saying the overwhelming response PASC received to the inquiry is “an indication of the devastating impact of clinical failures when things do go wrong”.
The example of patient Gina is given to illustrate the point. She had to have her leg amputated following an accidental injection of disinfectant during a routine angiography at Doncaster Royal Infirmary in 2013.
The report says: “Patients and NHS staff deserve to have clinical incidents investigated immediately at a local level, so that facts and evidence are established early, without the need to find blame, and regardless of whether a complaint has been raised.”
It adds that there also needs to be a “clear effective central system for disseminating the lessons learned from local incidents across the NHS nationally”.
The committee is extremely critical of the current systems in place to investigate clinical incidents, saying they are “complicated, take far too long and are preoccupied with blame or avoiding financial liability”.
“The quality of most investigations therefore falls far short of what patients, their families and NHS staff are entitled to expect, and these failures compound the pain and distress caused to patients and their families by the original incident,” the MPs say.
The committee also raises serious questions about the capacity and capability of the Parliamentary and Health Service Ombudsman (PHSO) in relation to complaints involving clinical matters, because of the “lack of timely, local, independent investigative capacity”.
Jenkin said: “We embarked on this inquiry because we are aware of the considerable anguish and disquiet where PHSO investigations fail to uncover the truth, and of pain inflicted by the Ombudsman when it has been defensive and reluctant to admit mistakes. This underlines the need for improved competence and culture change around clinical incident investigation throughout the system, including in the PHSO but across the board.
“That change is urgently needed. Some of the PHSO’s shortcomings are systemic and can only be addressed through legislation, which is needed early in the next Parliament. However, unhappiness with the Ombudsman underlines the need for improved capacity for clinical incident investigations in response to complaints, long before they reach the Ombudsman. To that end, we are calling for the establishment of this new, independent national patient safety investigation body, funded by the Department of Health.”
According to PASC a new national independent patient safety investigation body should meet the following criteria:
- Be transparent and accountable directly to Parliament.
- Offer a safe space with strong protections for patients and staff, so they can talk freely and without fear of reprisals about what has gone wrong.
- Be independent of providers, commissioners and regulators, and so able to investigate whether and how the system as a whole was instrumental in contributing to clinical failure.
- Have the power to publish its reports and to disseminate its recommendations. It should be for the Care Quality Commission and other executive, regulatory and commissioning bodies to ensure they are implemented.
- Have its own substantial investigative capacity, so that it can lead by example, oversee local investigations and conduct its own investigations when necessary.
A spokeswoman for the PHSO said: “We will carefully study this report which raises important issues about the investigation of clinical incidents for the health system, as well as about our service.”
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