Devastated families are being left without answers as deaths and negligence involving hospital patients in England are not being properly investigated.
Almost three quarters of hospital investigations into complaints about avoidable patient harm and deaths claimed there were no failings in the care provided. This is despite the Parliamentary and Health Service Ombudsman investigating the very same incidents and finding serious failings were made.
The Parliamentary and Health Service Ombudsman’s review into the quality of NHS investigations into complaints where serious or avoidable harm was alleged, found that inadequate hospital investigations were delaying urgently needed service improvements and leaving bereaved families without answers as to why their loved ones suffered negligence.
The report which was published on 8 December revealed that hospitals were failing to gather enough crucial evidence such as medical records, statements and interviews regarding serious incidents and failing to properly examine the limited evidence they did gather to ascertain the reasons behind why the incidents occurred in the first place.
The review was launched because the Parliamentary and Health Service Ombudsman, which investigates unresolved NHS complaints, found widespread variations in the quality of NHS investigations into avoidable death and harm. Based on a survey of NHS complaints managers, interviews with hospital staff and a review of the unresolved complaints brought to the Ombudsman, the report found that:
- the process of investigating was inconsistent and unreliable;
- Trusts failed to find any failings in 73 per cent of cases in which clear failings were identified by the Ombudsman;
- in more than 36 per cent of cases where failings were found, Trusts failed to discover why they had occurred, despite 91 per cent of NHS complaints managers claiming they were confident answers would be found;
- some NHS investigations into complaints about avoidable harm and death were not carried out by clinicians impartial to the incidents complained about;
- more than two-thirds of avoidable harm cases were not classed as serious incidents, and as such, were not properly investigated.
Parliamentary and Health Service Ombudsman Julie Mellor said, “Parents and families are being met with a wall of silence from the NHS when they seek answers as to why their loved one died or was harmed.
“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.”
The public needs to be confident that when serious clinical failings occur in hospital, the Trust concerned will thoroughly investigate what went wrong and provide answers to the families involved. When patients are needlessly harmed, not only must action be taken to ensure similar mistakes are not repeated, but it is crucial that hospitals acknowledge the extent of their failings and the distress caused to the patients and families concerned.
According to a survey of NHS managers, many frontline staff are not learning from investigations. This is because discussions between senior managers around what improvements need to be made following incidents of avoidable harm are not being shared with the staff who are actually providing the care.
Between 1 January and 1 December 2015 the Parliamentary and Health Service Ombudsman investigated 536 cases about potentially avoidable deaths and upheld 264. Complaints about potential avoidable deaths make up around 20 per cent of the NHS complaints the Ombudsman investigates.
The most common request I hear from families who instruct me to investigate whether their loved one died as a result of an avoidable mistake in their medical care is whether I can help them obtain answers as to what happened and why.
It is, therefore, essential that following care failures and negligence, hospitals share the answers of any subsequent investigations with the families involved. It is all too common to see investigation reports where no failings in the care given are found, only to then pursue a civil legal claim and discover that clear failings directly contributed to patient deaths.
This only ever serves to add further distress to an already upsetting situation for the families of those who have died and brings into question the integrity of NHS investigations into fatal hospital incidents.
Laura Craig is a clinical negligence solicitor at Slater and Gordon in London.
The Slater and Gordon clinical negligence team are widely experienced in handling claims related to hospital negligence.
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