The regulator’s review of how acute hospital trusts are learning from serious incidents comes only a week after the report of the Independent Review of Children’s Cardiac Services in Bristol. Many of the findings are not new - they mirror key issues highlighted in recent reports from the Public Administration Select Committee published in March, the Parliamentary and Health Service Ombudsman’s report in December 2015, the Morecambe Bay Inquiry and the Mid Staffordshire Public Inquiry. The review says they provide “further evidence of the need for a step change in the way that serious incidents are investigated and managed in the NHS.”
According to the CQC’s review they found a wide variation in the quality of investigations - in a third of investigation reports, it was not clear how the incident being investigated met the criteria for a full investigation under NHS England’s Serious Incident Framework. The review was based on a sample of 74 investigation reports from 24 NHS acute hospital trusts.
The CQC’s review will be shared with the newly formed Healthcare Safety Investigation Branch which is expected to be a centre of best practice for investigating incidents. While the regulator’s investigation looked at the acute hospital sector, its application will be of relevance to newer models of care, many of which may have less developed safety systems in place.
Learning from serious incidents – five learning points for hospitals
CQC’s review has drawn together five opportunities for improvement:
- Prioritising serious incidents that require full investigation and develop alternative methods for managing and learning from other types of incident
CQC found that some of the incidents reviewed would have “benefited from alternative approaches, using less complex but more efficient ways to address the needs of the patient(s) and to identify any mitigating actions that could prevent the incidents happening again.”
- Involving patients and families in investigations in line with the Duty of Candour
Only 12 per cent of the sample reports included clear evidence that the patient or family had been involved in the investigation although only 36 per cent included any evidence that the patient or their family had been offered a chance to discuss the report.
- Engaging and supporting staff in the incident and investigation process
The regulator found that only 39 per cent of the reports included evidence of interviews with members of staff who were involved in the incident.
- Improving the methodology and analysis of the causes of the incident
Very few of the reports reviewed included evidence of a well-structured investigation and the use of the Serious Incident Framework’s tools and templates. Often, reports had unanswered questions or unexplained issues.
- Using human factors principles to develop solutions that reduce the risk of the same incidents from happening again
As part of CQC’s review it looked at how the recommendations from the investigation reports had reduced the risk of incidents happening again. It found that in 35 per cent of reports there was a positive response, indicating that CQC could see how the suggested recommendations and actions could reduce the risk of recurrence even if the investigation methodology was not clear. However, only 28 per cent of reports followed the investigation guidance and recorded a risk assessment following the investigation and the planned actions.
Trust boards need to ask “if their investigations are making a difference and leading to improvement”
CQC’s review provides a timely opportunity to remind providers of the importance of developing capacity and capability to embed good investigative practice into their wider approach to learning and improvement when investigating incidents.
Do get in touch with us if you require assistance with your serious incident investigations or need help with training your staff.