More than a third of NHS investigations regarding allegations of avoidable harm or avoidable death were inadequate and failed to identify when something had gone wrong.
The Parliamentary and Health Service Ombudsman reviewed 150 complaints it had already investigated and looked at the quality of trusts’ investigations into complaints.
Twenty eight of the 150 cases should have been investigated by the NHS as a Serious Untoward Incident. Of those 28 cases, 71% had a complaint that did not trigger an SUI investigation.
Parliamentary and Health Service Ombudsman, Julie Mellor, said: “Investigations weren’t carried out when they should have been and when they were carried out they did not find out or explain why failings happened.
“When people make a complaint that they have been seriously harmed they should expect it to be taken seriously and thoroughly investigated.
“The NHS must tackle the variation in the quality of its investigations but also needs to recognise when to initiate an investigation.”
The review focused on acute trusts and a series of questions were asked about the quality of the NHS investigation and the evidence relied on.
Questions included: whether the original investigation had access to all the relevant clinical records, had obtained written statements, interviewed key staff, and obtained a clinical review and whether that was independent.
In one case, the Parliamentary and Health Service Ombudsman investigated a 77-year-old man who was admitted to hospital because he felt very unwell. His condition deteriorated and died two days later as the result of sepsis.
The man’s daughter discussed her concerns about his care with hospital staff. The hospital’s head of nursing investigated the complaint but there is no evidence they interviewed or obtained statements from clinical staff.
The ombudsman investigation found despite the man’s poor health the clinical staff who saw him during the initial period did not recognise the severity of his illness, which meant he was not seen by a doctor for more than two hours, observations of his condition were not taken frequently, and antibiotics were not started until four hours later.
It was unable to conclude the man’s death could have been avoided but considered the hospital missed an opportunity to give him the best chance of recovery by failing to give him more timely treatment. None of these findings were identified in the hospital’s investigation and if they had this may have triggered a serious untoward incident investigation.
Mellor added: “‘When the NHS makes a mistake their duty is to investigate – these investigations shouldn’t be about attributing blame but should find out what happened and why in order to prevent the same mistakes from happening again. Our evidence too often shows this is not the case.”
The ombudsman concluded 3,189 investigations about the NHS in 2014. Of these concluded NHS investigations, 333 included allegations of avoidable death. Of these 333, the ombudsman identified 150 as part of this review, which it considered raised issues of serious avoidable harm or death.
10,000 severe harm or death incidents are reported into the National Reporting and Learning System per year in acute care settings. This equates to 200 incidents per week.