The current NHS England national serious incident framework outlines the need to make sure that investigations into serious incidents are carried out for the purposes of learning to prevent 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.