Many NHS probes into avoidable deaths ‘not fit for purpose’, ombudsman warns
Many investigations into avoidable deaths in the NHS are inadequate, the health ombudsman has warned.
The Parliamentary and Health Service Ombudsman (PHSO) said that many of these inquiries are “not fit for purpose”.
Meanwhile, the health service’s top investigator said not all hospitals were displaying a culture of learning from mistakes.
And some serious incidents in the NHS could be avoided if the NHS had a better “learning culture”, Professor Sir Mike Richards, chief inspector of hospitals at the Care Quality Commission, told the Public Administration and Constitutional Affairs Committee.
Prof Richards told MPs: “We have put increased emphasis on how trusts do investigations and how they select which cases need to be investigated, how they actually undertake the investigation, but most importantly what they learn.
“One of the questions I ask chief executives when I am inspecting hospitals is: ‘Can you tell me something that has gone wrong and a change you have made as a result of that?’
“There are cases where someone will say, ‘we have conducted this investigation and as a result we have made the following changes so it is much less likely to happen again’.
“But I wish I could say that was true across the country.”
He added: “There are still serious incidents that could be avoided in the future if we had a learning culture. What we collectively need to do is to push the system towards a being a learning system rather than a blaming one.”
The comments come as the father of a three-year-old boy who died after a string of blunders by NHS workers said that lessons were only just beginning to be learned following his son’s death almost six years ago.
Sam Morrish died two days before Christmas in 2010 from sepsis, but the PHSO said his death could have been avoided had he received appropriate care from four separate health service organisations.
In a supplementary report, the PHSO examined why NHS investigations failed to uncover that his death was avoidable. It concluded that the investigations were not sufficiently independent, inquisitive, open and transparent and properly focused on learning.
Sam’s father Scott Morrish, from Newton Abbot, Devon, said there was a need to end a culture of blame and shame in the system.
He told MPs: “One of the things that has troubled me the most is that I was pigeon-holed as a problem from the very beginning.
“Actually the way the system functioned, it had a closed mind from the minute Sam died to the idea that anything had gone wrong and that there could be any learning.
“We just need to shift the whole focus away from that blame and shame, and the worries that go with that, to one where the expectation is learning no matter what happened.
“So whether it’s good or it’s bad, we can learn and we can improve.
“And just to have an expectation of supporting staff and supporting families and not pitting us against each other and hopefully these things won’t keep happening.”
Commenting on the hearing, PHSO Dame Julie Mellor said: “Sadly the experience of the Morrish family is not unique.
“We see too many local NHS investigations into avoidable deaths that are not fit for purpose.
“We have recommended that people at the top of the NHS consider how they can create an environment in which leaders and staff in every NHS organisation feel confident and have the competence to find out why something went wrong and to learn from it.”
The hearing occurred as the Royal College of Physicians (RCP) set out plans to standardise how adult hospital deaths are investigated.
The college said that up to 15% of people who die in hospital have some problem with their care.
And 3% of deaths could potentially be avoided.
The RCP said that it aims to replace investigations systems across England and Scotland with a single, standardised mortality review.
This has the potential to “maximise learning and improvement”, a spokeswoman said.
Dr Kevin Stewart, of the RCP, said: “When things go wrong in healthcare, what patients and their families want more than anything else is that we will learn and improve our systems as a result, so reducing risk for future patients. They also expect that we will learn from and spread good practice.”
A Department of Health spokeswoman said: “We want the NHS to be the safest healthcare system in the world. Families deserve an explanation if their loved ones pass away under NHS care, as well as assurances that any mistakes will not be repeated.
“Our new independent investigations unit and an upcoming review on death investigations will improve the quality of these inquiries across the NHS.”
Copyright (c) Press Association Ltd. 2016, All Rights Reserved. Picture (c) Peter Byrne / PA Wire.
