An urgent overhaul is needed of how hospitals examine serious NHS complaints made against them.
This is the key finding of a high level review of how hospitals investigate mistakes that have allegedly led to patients being harmed or killed.
The review, led by Dame Julie Mellor, the parliamentary and health service ombudsman, finds that inquiries by hospitals are often inadequate and result in complainants being met with “a wall of silence”.
In 73% of cases in which she found evidence of clear failings, the NHS hospitals trust concerned had concluded that no failings occurred.
Mellor said: “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.”
In just over half (52%) of the cases she examined, the investigation had been led by a doctor who was not independent of the events complained about.
For example, when a baby girl was left with brain damage after a blood transfusion went wrong, the hospital appointed a close colleague of the paediatrician at the centre of the complaint to investigate.
The girl’s family had to wait three years before learning what mistakes had been made.
Hospitals also failed to categorise 20 out of 28 cases of avoidable harm examined as serious incidents, which meant they were not properly investigated.
The review concluded that hospital inquiries into serious injuries or deaths too often fail to gather enough evidence, are inconsistent in how they look for proof of errors, and do not look closely enough at material to see what went wrong and why.
Almost a fifth (19%) of inquiries did not gather important evidence such as the patient’s medical records, statements and interviews, Mellor found.
Rob Webster, CEO of the NHS Confederation, said: “When care goes wrong an NHS complaints system needs to have a golden thread where patients and their families receive an apology, an explanation and a clear description of the lessons that have been learned. This is one of the fundamentals of an effective and safe healthcare system.
“We know we don’t always get this right and it’s crucial that we learn and improve every time. The Care Quality Commission’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. So we urgently need to learn from what is working and fix what doesn’t, to ensure patients have complete confidence in the National Health Service.”