Last week, the NHF published its final version of its new Code of Governance and made some important changes from the previous draft that will impact on those housing associations looking to adopt it.
All hospitals are under an obligation to investigate serious incidents in their hospitals. The purpose is to learn from the mistakes in order to prevent recurrence and so protect patient safety.
The Parliamentary and Health Service Ombudsman found that some hospital investigations were inadequate, of poor quality, inconsistent, not transparent and not independent.
Dame Julie Mellor, the Ombudsman, said “NHS investigations into complaints about avoidable death and harm are simply not good enough”.
The Ombudsman’s report found that a fifth of NHS investigations missed crucial evidence, an independent doctor was involved in only 52% of the investigations and in 73% of cases where the ombudsman found clear failings, the hospitals’ own investigations claimed that there were no failings. Furthermore, even when hospitals identified failings, the lessons were not passed to frontline staff so no improvements would follow.
The report called for an accredited training programme for staff carrying out investigations and new guidance.
Ann Houghton, clinical negligence solicitor at Anthony Collins Solicitors, said “many of our clients have first-hand experience of this system and the feeling of hitting their head against a brick wall when they just want to know what happened and that things will change so that other patients are safe. This report shows that sadly our clients’ experiences are not isolated events. It is particularly worrying that some investigations might not be independent and there might be a degree of ‘turning a blind eye’ to failings.
Recognising where things have gone wrong, apologising and learning from the mistake is of crucial importance in the NHS, the same as in every other business and life generally. The failings of the present system also mean people are turning to litigation in order to get answer because of the brick wall they face after making a complaint. This can be stressful for patients and costly for the NHS, both of which could often be avoided if the NHS investigations were better in the first place.”
For further information or advice about the issues raised here, please contact Ann Houghton
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