The NHS introduced the Patient Safety Incident Response Framework (PSIRF) with the aim of improving patient safety by avoiding a repeat of the same issue. But even with such a framework in place, there are occasions where issues affecting patient safety are allowed to persist.
Verita was commissioned to conduct an independent review of a complex and serious matter concerning paediatric orthopaedic services at a prominent NHS Trust. The aim was to identify if there were any missed opportunities to have identified concerns and acted earlier so that patient harm could have been avoided.
Serious healthcare incidents are complex, and it may not be possible for internal teams to look into them without bias. To make sure real lessons are learned and services genuinely improve, a totally fair and transparent process is required. That is the quickest way to rebuild confidence and trust with patients and the public.
Our role as a specialist independent investigation company is to provide objective, evidence-based analysis and deliver recommendations that ensure patient safety and restore public trust. In this article we explore key systemic insights for improving clinical governance after a serious incident has occurred.
The challenges of an internal investigation
In high-profile cases such as this, the problem with having an organisation investigate itself is that internal loyalties and conflicts of interest are almost impossible to avoid. It’s just human nature and people may feel pressure to protect their colleagues, their managers, or the organisation’s reputation. This can mean facts get accidentally overlooked or conclusions get softened.
An independent investigator avoids these issues because they don’t have those existing relationships. Asking difficult questions and following the evidence wherever it leads can take place without any fear or pressure, resulting in completely objective findings. This provides a foundation on which learning and improvement can take place.
In addition to improving patient safety, a report from an impartial, outside expert which is likely to be read by the public, the media, and regulators, not just the board, is instantly more trustworthy and credible, which is absolutely essential for rebuilding confidence quickly.
Reviewing a serious incident
When we carry out a serious incident review there are some key areas which often require investigation, such as:
- Thorough review of complex medical and governance documentation: Report on any gaps in systems, processes and governance arrangements and make appropriate recommendations for learning and improvement. Identify any ‘hard data’, such as complaints and patient safety incidents, or ‘soft signals’ relating to the subject of the investigation and comment on the appropriateness of any action taken in response to these.
- Confidential interviews with staff and leadership: Investigation can take place in private, interviewing a range of people including consultants, managers, staff and executive directors. As well as individuals suggested to the investigator, others can be contacted if their contribution is considered to be of material importance.
- Applying a clinical governance lens to identify systemic, not just individual, failures: Look at culture, management structures, resource provision, systems, processes, policies and procedures, to identify where improvements can be made and make recommendations accordingly.
Systemic lessons learned
This type of investigation can uncover a range of systemic issues, providing recommendations which can be applied to other healthcare organisations.
Our report made a total of 23 recommendations which cover areas from governance and external reviews, to culture and communication. Here are some examples of the type of systemic issues which can be identified during a serious incident investigation like this:
Clinical governance and oversight
Clear lines of accountability are vitally important for clinical quality. Line management arrangements, and the responsibility for their clinical supervision should be clearly outlined to enable issues to be identified and appropriate measures put in place.
Governance and management systems should be able to detect any difficulties with clinical practice to avoid patient safety being unnecessarily adversely affected. An example of this is establishing an implementation working group, including corporate management and representation from key groups of staff responsible for patient safety, which ensures that changes to clinical governance structures, processes and practice are embedded effectively across the organisation.
Multi-disciplinary meetings (MDT) are an important mechanism to share cases with colleagues and mandatory attendance ensures there are no missed opportunities to discussing patient safety issues. If these meetings are properly structured they will allow for the identification of concerns about a surgeon’s clinical practice.
Whistleblowing and culture
Culture is one of the pillars of patient safety because a Just Culture where staff feel empowered to raise concerns without fear of retribution enables issues to be identified and resolved before they escalate. It is also crucial that incident reporting mechanisms function as they should in order to give confidence to staff that using them to report issues will result in positive action. Internal reporting routes such as this, if functioning correctly, should provide a quicker and more efficient route to enacting positive change than external routes such as whistleblowing.
Excessive workloads can impact on patient safety and quality of care. Having arrangements in place for line management to understand whether any reasonable adjustments need to be made to support individuals to maintain good health and performance is vital in this regard. Not only does it ensure that the organisation meets its legal duties under equality and disability legislation, it also promotes an inclusive and supportive work environment, and helps to retain valuable employees by maximising their potential and reducing the risk of long-term sickness or poor performance related to unmet needs.
Clinical communication
Clear communication protocols are essential, especially during periods of change or service reconfiguration. Effective communication within teams is also vital because if breakdowns of relationships occur it can lead to a lack of collaboration which can adversely affect patient safety.
Line management should address any issues and employ informal approaches such as encouraging colleagues to talk through issues or utilise more explicit conflict resolution or mediation if problems persist.
Regular, objective external oversight is essential for high-risk services, ensuring they are benchmarked against best practices and consistently meet a high standard of quality. Developing written guidance on the commissioning of external reviews in collaboration with line managers should be set out in a standard operating procedure (SOP) to ensure reviews are properly specified, that their findings and recommendations are actioned, and that appropriate monitoring arrangements are established to track progress with any improvement plans.
Conclusion
Investigations such as these should never be about looking at what went wrong, they should be designed to deliver actionable recommendations which address systemic issues. Our recommendations often lead to overhauled governance and safety systems where new, clearer ways of working are put in place, making the entire service stronger and safer for the long term.
We help organisations develop a stronger patient safety culture where staff feel empowered to speak up and that issues are caught much earlier, before they escalate. Crucially, our reports provide future resilience and protection by identifying systemic vulnerabilities in areas like communication, oversight, or clinical governance, providing leaders with the tools they need to prepare for and prevent similar incidents from happening later down the line.
If you need help with an independent investigation, or would like to know more about our healthcare consultancy or serious incident investigation services, please book a free consultation, or if you prefer, use our contact form, or contact Ed Marsden on 020 7494 5670 or [email protected].
