NHS hospitals 'too quick to absolve staff of blame in wake of serious errors'

NHS hospitals are too quick to absolve staff of blame in the wake of serious errors that cause harm to patients, the parliamentary health watchdog has said.

Internal investigations into cases of avoidable harm or death are not "consistent, reliable or transparent", Parliamentary and Health Service Ombudsman (PHSO) Dame Julie Mellor said, and nearly half were carried out by clinicians who were not independent of the events complained about.

This included a review of the death of a baby girl, which was investigated by a close colleague of the paediatrician who had been in charge on the day mistakes occurred, the report said.

Dame Julie accused NHS trusts of putting up a "wall of silence" to families of those who died or were harmed when they questioned what happened, and called for a new training regime for NHS staff carrying out investigations.

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Nearly three quarters of hospital investigations into avoidable harm found no failings – despite the PHSO later identifying problems when looking at the same incidents.

Almost a fifth of NHS investigations were missing crucial evidence, such as medical records, statements, and interviews, and more than a third of those which recorded failings did not get to the bottom of why they had happened. Nevertheless, nine out of ten complaint managers said they were confident they could find answers.

Patient safety groups said that “a complete rebuilding of trust” in the NHS complaints system was required.

Dame Julie 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.

“We want the NHS to introduce an accredited training programme for staff carrying out these investigations as well as guidance on how they should be done, so the public can be confident that when someone is needlessly harmed it has been thoroughly investigated and answers provided, so that action can be taken to prevent the same mistakes from happening again.”

Anna Bradley, chair of patient safety monitor Healthwatch England, said hundreds of thousands of incidents of poor care were going unreported each year “because people fear they either won't be taken seriously or that nothing will change as a result.”

"In order to change this we need a complete rebuilding of trust in the complaints system, starting with the way in which hospitals and health professionals review incidents of avoidable harm and death. Guaranteeing the quality, integrity and consistency of the way in which the worst cases are investigated must go hand-in-hand with measures to ensure lessons are learnt across the whole of the health service,” she said.

Peter Walsh, chief executive of Action Against Medical Accidents (AvMA) said the findings were “doubly worrying” as the PHSO only reviewed cases where there had already been a complaint.

“If this is how the NHS investigates when there is a formal complaint, one has to wonder how it investigates when it is left entirely to its own devices. Unfortunately, in our experience it is not uncommon for NHS bodies to carry out investigations without even informing the patient or family affected by an incident,” he said.

Rob Webster, chief executive of the NHS Confederation, which represents hospital managers, said: ““We know we don’t always get this right and it’s crucial that we learn and improve every time. [Health inspectorate] the Care Quality Commission’s review of complaints recognised more good practice than poor in its report from December 2014 and we should draw strength from those examples. At the same time, the CQC, Ombudsman and others are highlighting major inconsistencies and shortcomings in the handling of complaints and those problems cannot be allowed to continue. So we urgently need to learn from what is working and fix what doesn’t, to ensure patients have complete confidence in the National Health Service.”