Investigating clinical incidents
The Public Administration Select Committee published its report on investigating clinical incidents in the NHS last Friday (27 March). Verita submitted written evidence to the inquiry and Ed Marsden, Verita’s managing director, answered questions at a public hearing.
The report says that the current processes in the NHS for investigating and learning from incidents are “complicated, take far too long and are preoccupied with blame or avoiding financial liability”. It argues that the quality of most investigations is poor and that “these failures compound the pain and distress caused to patients and their families by the original incident”. It goes on to recommend the setting up of a national independent patient safety investigation body. The comparator with the airline industry particularly influenced the recommendation:
“experience in other safety-critical industries such as aviation demonstrates how resources devoted to investigating and learning to improve clinical safety will save unnecessary expense by reducing avoidable harm to patients. Investigations should wherever possible be conducted locally, but the local resolution is too often slow, conflicted, defensive and of poor quality. The new body must be primarily a centre of expertise and promoter of good investigatory practice and expertise.”
One issue with the committee’s proposal is the scope of the work the new body will carry out. The number of incidents in the airline industry is tiny compared with that in the NHS. The Department of Health estimates there are 12,000 avoidable hospital deaths every year and more than 10,000 serious incidents reported to NHS England annually. In comparison, in 2013 there were 138 accidents leading to 265 deaths worldwide in the airline industry.
Verita’s submission emphasised the importance of local investigation. Those closest to the incident are in the best position to know what went wrong and what changes need to be made – and are in the best position to deliver the changes. The priority should be to give those people the right tools and support to deal with issues. The committee seems to recognise this dilemma saying that there will have to be “clear criteria” for deciding which incidents the new body investigate to avoid it being overwhelmed.
It will be interesting to see what these “clear criteria” are. While a body that supports local resolution of issues might be worthwhile, centralisation could make things worse if there is a tendency for more and more incidents to be investigated by the national body. Which family will settle for local resolution if the option of a national investigation is on the table and how will a national body ensure that learning is put into effect at a local level?
As always, the devil will be in the detail…