How to learn from serious incidents
The current NHS England national serious incident framework outlines the need to carry out investigations to make sure that learning from serious incidents happens for the purposes of preventing recurrence. Despite this guidance, there is evidence that the same type of incident happens again and again across the NHS.
In our experience, there is too much focus on the investigation itself. Many investigations reports are long, repetitive, poorly focused and do not really get down to the real reasons why something has gone wrong. By the time the investigation is complete, investigators have run out of steam so not enough effort is made to put things right to reduce the same type of incident happening again. In addition, many investigators have not been trained in human factors so do not have the knowledge or skills to develop solutions to address the underlying cause of an incident.
The CQC carried out a review of the quality of NHS trust investigation reports in June 2016. They have supported our view by recommending that serious incidents requiring a full investigation should be prioritised and that NHS trusts should develop alternative methods for managing and learning from other types of incidents.
Real learning from serious incidents requires a fair, open, and just culture; one that abandons blame and promotes the belief that incidents cannot simply be linked to the actions of the individual healthcare staff involved, but rather the system in which the individuals were working. By acknowledging human limitations, a human factors approach recognises that human performance can be improved by an understanding of the effects of teamwork, tasks, equipment, workspace, culture and organisation. Having a whole system/human factors approach to developing solutions will reduce the risk of the same incidents happening again and put things right.
Serious incident investigations – time for a change?
The NHS continues to work towards effective learning from serious incidents and in August 2022 the Patient Safety Incident Response Framework (PSIRF) was published which will replace the current Serious Incident Framework. There will be a 12 month period where organisations prepare for the transition and although it is a new approach, the purpose is the same, that being to learn from serious incidents and improve patient safety.
Whichever framework is used, healthcare involving serious incident investigations is a complex world, where time is a luxury frontline staff simply don’t have. That’s something we can all agree on. And with budgets being pinched, the value gleaned from each pound spent is being scrutinised to the nth degree. So, of course, any investment made by an organisation has to be beneficial to as many people as possible. And that’s where we come in.
Our game-changing new product, Eva, transforms the way serious incident investigations are conducted in public and private hospitals across the UK. This is a product that hauls incident investigation into the 21st century, making it less of an ordeal for frontline staff to complete, patients to engage with, and IT staff to implement. The app standardises the process and is incredibly intuitive and easy to use while being cost-effective and simple to integrate with existing IT systems. So, the benefits are clear.
Eva isn’t just about easy integration and better investigations. It also offers the benefit of anonymised data aggregation and thematic analysis across multiple locations, meaning it will finally be possible to have informed insights and identify trends, ultimately reducing the number of serious incidents that occur. And this benefit will stretch to boardroom level too, where the likelihood of reduced insurance premiums and lower litigation costs will give care-devoted budgets a much-needed boost.
Learning from serious incidents – a case study
In 2011, the Devon and Cornwall Police launched an investigation into alleged abuse at several care homes across Devon, which had been run by Atlas Projects Ltd for people with learning disabilities. Looking into serious incidents, this investigation in October 2013, the police commissioned Verita to review the care provided to residents at several of the homes owned by Atlas, and to provide expert advice in terms of standards of care for people with learning disabilities.
Verita reviewed an extensive range of care records, guidelines and protocols that had been produced in 2010-11 and analysed these against minimum standards. A number of written reports were produced by Verita during 2013 – 2016, all of which described a shocking and punitive culture that prevailed at both Veilstone and Gatooma care homes. In addition, Verita provided expert advice for police interviews, as well as for each of the court trials held during 2015 and 2016.
The court heard how residents had been repeatedly and systematically detained in rooms that had no heating, and little or no furniture or toilet facilities, sometimes for several hours at a time – or even overnight. Four company directors and nine employees were sentenced in relation to the abuse of residents at two of the Atlas care homes in Devon. This case has been ground-breaking in that the directors and managers of the homes – not just the direct care staff that implemented the policies – have been held to account. The reporting restrictions were lifted by the court on 7 June 2017.
The stress and pain that individuals and their families have endured has been considerable. Atlas Project Ltd was established to provide specialist services for their clientele at a cost of £4,000 per week per person, and they failed to deliver an appropriate model of care for those with complex needs, leaving individuals subjected to systematic abuse over a two-year period. Commissioning, and the inspection of services for people with learning disabilities, need to be strengthened to ensure that abusive cultures cannot develop or be sustained.
Embracing a culture of learning from serious incidents
Although there are lots of examples of good practice within the health service – we have more work to do to fully embrace a culture of learning from serious incidents to improve patient safety.
Verita provides a serious incident management service which aims to target problem areas and develop solutions so that reputational damage and costly legal claims can be avoided. Our experience in over 200 serious incident investigations helps Trusts ensure they have robust systems in place to investigate serious and critical incidents so that themes are identified and lessons learned across the organisation.