Almost half of NHS probes in to avoidable deaths are ‘NOT fit for purpose’, health officials warn
TOO MANY probes in to avoidable deaths in the NHS are inadequate and “not fit for purpose”, the health ombudsman has warned.
Dame Julie Mellor said some bosses and staff lack the confidence and competence to find out why something has gone wrong – and then learn from it.
Her comments followed a Public Administration and Constitutional Affairs Committee hearing today into the NHS investigations.
A Parliamentary and Health Service Ombudsman report published in December 2015 found four in ten probes failed to adequately establish what had happened.
And the PHSO fully or partly upheld 279 of the 625 complaints into potentially avoidable deaths that it examined between January and September this year.
We see too many local NHS investigations into avoidable deaths that are not fit for purpose
Dame Julie Mellor
The PHSO said Sam Morrrish’s death from sepsis – two days before Christmas 2010 – could have been avoided had he received appropriate care from four separate health service organisations.
And it concluded the investigations in to his death were not sufficiently independent, inquisitive, open, transparent or 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.”
PHSO Dame Julie Mellor said after the hearing: “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 health service’s top investigator told the Commons hearing that not all hospitals are displaying a culture of learning from mistakes.
Professor Sir Mike Richards, chief inspector of hospitals at the Care Quality Commission, said some serious incidents in the NHS could be avoided if the organisation had a better “learning culture”.
He said: “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'.
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
Professor Sir Mike Richards
“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 hearing occurred as the Royal College of Physicians set out plans to standardise how adult hospital deaths are investigated.
The college said that up to 15 per cent of people who die in hospital have some problem with their care and 3 per cent of deaths could potentially be avoided.
The RCP said 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.”