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Serious failings in hospital-led investigations, says ombudsman – but patients say it is at fault too

The NHS has been urged to introduce a training programme for staff carrying out probes into complaints about avoidable harm and death, after the Parliamentary and Health Service Ombudsman (PHSO) identified serious failings in these hospital-led investigations.

While the PHSO uncovered serious failings in 73% of its investigations into complaints about avoidable harm and death, nearly three-quarters of earlier hospital-led investigations into these concluded there were no mistakes in the care given.

The ombudsman has blasted these inadequate hospital probes that only serve to leave “distraught patients and families without answers”, as well as delaying vital improvements needed in the NHS. 

The Patient's Association has said these messages echo its own findings – but that the ombudsman service itself is also partly to blame, and sometimes just a 'paper exercise'.

Hospitals fail to investigate matters properly because they do not gather enough evidence, the ombudsman’s report has argued – using inconsistent methods and not looking at evidence closely enough to find out what went wrong, and why. Some investigations are also not being carried out by staff sufficiently removed from the incidents complained about in the first place. Where a clinician reviewed what had happened, for example, only half of them used a clinician who was independent of the events.

The health ombudsman, Julie Mellor, said: “Patients and families are being met with a wall of silence from the NHS when they seek answers as to why their loved one died or was harmed.

“Our review found that NHS investigations into complaints about avoidable death and harm are simply not good enough. They are not consistent, reliable or transparent, which means that too many people are being forced to bring their complaint to us to get it resolved.

“We want the NHS to introduce an accredited training programme for staff carrying out these investigations as well as guidance on how they should be done, so the public can be confident that when someone is needlessly harmed, it has been thoroughly investigated and answers provided, so that action can be taken to prevent the same mistakes from happening again.”

The ombudsman’s report found that hospitals failed to class more than two-thirds of avoidable harm cases as serious incidents, meaning these were not properly investigated. One-fifth of investigations carried out missed crucial evidence, such as medical records, statements and interviews.

More than one-third of locally-led investigations which did record failings did not find out why they had happened, despite 91% of NHS complaint managers saying they are confident that they could find out answers.

Its report and review of local hospital investigations was originally prompted by the wide variation the ombudsman found in the quality of complaints investigations carried out by the NHS.

Rob Webster, chief executive of the NHS Confederation, admitted that the health service doesn’t always manage to issue apologies, explanations and descriptions of complaints, despite describing these as “one of the fundamentals of an effective and safe healthcare system”. But he said the NHS must be able to learn and improve every time, which he argued it has – “The CQC’s review of complaints recognised more good practice than poor in its report from December 2014, and we should draw strength from those examples. At the same time, the CQC, ombudsman and others are highlighting major inconsistencies and shortcomings in the handling of complaints and those problems cannot be allowed to continue,” Webster added.

“So we urgently need to learn from what is working and fix what doesn’t, to ensure patients have complete confidence in the NHS.”

‘The health ombudsman is also at fault’ – Patients Association

The health secretary, Jeremy Hunt, posted on Twitter that the findings about the “wall of silence” on NHS complaints was worrying, and claimed it was vital that the health service changes to a culture of openness, transparency and learning from its mistakes.

A Department of Health spokesman gave a similar message, saying the government wants to make the NHS “the safest healthcare system in the world, and it is vital that the NHS makes sure all investigations serve the needs of patients and families”.

But Katherine Murphy, chief executive of the Patients Association, was less optimistic, claiming that while findings were inexcusable, they were far from surprising.

“The Patients Association has known for many years that NHS investigations into patients complaints have not been good enough. Patients have been suffering in silence for too long,” she said.

And the health ombudsman itself also contributed to the problems identified in its report, Murphy argued.

“They have had opportunities for many years to improve complaints handling for patients. Our report in March 2015, ‘PHSO: Labyrinth of Bureaucracy’, highlighted how many patients faced a number of issues dealing with the PHSO. These issues ranged from sub-standard investigation reports to patients not being listened to or believed. Too often, the PHSO has ignored patients and simply gone along with the findings of the NHS trust,” she continued.

“The PHSO must use the findings of their report and make sure that their work is more than just a paper exercise. Patients must be involved and engaged in the complaints process so they have confidence they will get answers, and stop the same mistakes from happening again.”

Patient safety charity Action Against Medical Accidents had a similar message. Peter Walsh, its chief executive, said the ombudsman must improve its own investigations.

“The ombudsman’s findings are doubly worrying, as they were only reviewing cases where there had already been a complaint under the NHS complaints procedure. If this is how the NHS investigates when there is a formal complaint, one has to wonder how it investigates when it is left entirely to its own devices,” he said.

“Unfortunately, in our experience, it is not uncommon for NHS bodies to carry out investigations without even informing the patient or family affected by an incident.”


Angus   09/12/2015 at 12:59

NHS Managers (including doctor and nurse leaders) are paid far less than people carrying equivalent responsibilities in other industries. It is at best stupid to expect that processes and outcomes will be as good as in those industries which will inevitably attract the best talent (despite a few highly committed individuals doing their best despite the system).

Jools   09/12/2015 at 14:48

Not only am I a Registered Manager within the Private Sector; but a mother who's son died due to a catalogue of medical mistakes; it took me three years to extract the truth as to what happened very much closed doors; missing X-rays etc - no parent should not only have to go through this battle for the truth whilst grieving and having to support his brother and sister. To receive an apology letter 3 years down the line while reassurances that changes have been implemented ( this was16 years ago) it appears it was a smoke screen. The Care Homes have been under the spot light by Health Authorities; Councils and CQC with yearly inspections which are robust; it appears that CQC are now looking more closely at the NHS ( Nurses are paid more in the NHS than the Private sector) . We carry out frequent assessments at the NHS and all to frequently see errors; concerns and neglect; like us we are snowballed with paperwork but unlike the NHS we have to be open and transparent to all the authorities; relatives and service users.

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