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New body should investigate clinical incidents

A national body to investigate patient safety issues in England should be established immediately, an all-party committee of MPs has urged.

The House of Commons Public Administration select committee said that following Mid Staffs and Morcambe Bay a simpler system to investigate clinical incidents service was needed.

The committee said the current patient safety system was “too complicated” and “took too long”.

Dr Bill Kirkup’s review into Morecambe Bay revealed that 11 babies and one mother had died unnecessarily at Cumbria’s Furness General Hospital, but the scandal had gone unchecked for years.

It is estimated that there are 12,000 avoidable hospital deaths every year, and more than 10,000 serious incidents are reported to NHS England annually, including 338 “never events” such as surgery being carried out on the wrong part of the body.

The NHS Litigation Authority’s latest estimate of clinical negligence liabilities is £26.1 billion.

The committee said patients and NHS staff deserve to have clinical incidents investigated immediately at a local level, so that facts and evidence are established early, without the need to find blame, and regardless of whether a complaint has been raised.

It also said there is a need for a clear effective central system for disseminating the lessons learned from local incidents across the NHS nationally.

The current NHS processes for investigating and learning from untoward clinical incidents are complicated, take far too long and are preoccupied with blame or avoiding financial liability, it concluded.

The quality of most investigations therefore falls far short of what patients, their families and NHS staff are entitled to expect, and these failures compound the pain and distress caused to patients and their families by the original incident.

Many bodies promote safety in the NHS, including the Care Quality Commission and the Parliamentary and Health Service Ombudsman (PHSO), and scores of bodies play a role in complaints and safety investigation, but there is no systematic and independent process for investigating incidents and learning from the most serious clinical failures.

The Committee also raises serious questions about the capacity and capability of the Parliamentary and Health Service Ombudsman – currently the ‘court of last resort’ – in relation to complaints involving clinical matters, because of the lack of timely, local, independent investigative capacity.

The Committee says a new national independent patient safety investigation body must:

-be transparent and accountable directly to Parliament.

-offer a safe space with strong protections for patients and staff, so they can talk freely and without fear of reprisals about what has gone wrong.

-be independent of providers, commissioners and regulators, and so able to investigate whether and how the system as a whole was instrumental in contributing to clinical failure.

-have the power to publish its reports and to disseminate its recommendations. It should be for the Care Quality Commission and other executive, regulatory and commissioning bodies to ensure they are implemented

-have its own substantial investigative capacity, so that it can lead by example, oversee local investigations and conduct its own investigations when necessary.

Bernard Jenkin MP, Chair of the Committee, praised the health secretary saying he appears to have accepted that the investigative body should be created.

“Ever since the MidStaffs hospital crisis and the Francis Report, it has been evident that the NHS has urgent need of a simpler and more trusted system for clinical incident investigation at both local and national level. This was again confirmed by the Kirkup report into the Morecombe Bay baby deaths.

“There needs to be investigative capacity so that facts and evidence can be established early, without the need to find blame, and regardless of whether a complaint has been raised. Our proposals for a new investigatory body will help transform the safety culture of the NHS and help to raise standards right across the NHS. This proposal is widely supported and it should be taken up early in the new Parliament.”

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One Response to “New body should investigate clinical incidents”

  1. Malcolm Morrison says:

    Do we really need a ‘new national body’? Do we not have too many already (that cause the confusion as to which, if any, are ‘responsible’)?

    What is needed is for the present ‘bodies’ to work faster and more effectively!

    The first port of call for a clinical complaint should be the consultant(s) under whose care the patient was treated. They should be allowed to ‘explain’ (if they can) what went wrong (if it did) and what they are going to do to try to prevent it happening again. We are told, all too often, that had complainants been able to do this, a lot of litigation might be avoided,

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