RCoA response to NHS Improvement’s consultation on the future of NHS patient safety investigation

The Royal College of Anaesthetists, alongside other medical royal colleges and safety-related organisations, has been invited to share its views on how and when the healthcare system should investigate and respond to serious incidents. This consultation will inform the review of the Serious Incident Framework in order to develop national guidance on the systems, processes and behaviours that providers, commissioners and oversight bodies are expected to adopt to ensure that NHS organisations respond appropriately when things go wrong. 

Our submission highlights the opportunity that this review presents to facilitate a ‘no blame’ culture within the NHS, where emphasis is placed on learning from mistakes. In summary, we believe that the issues that require addressing in the current framework are as follows:

  • Highlighting positive as well as negative aspects of the cases investigated will improve the engagement of staff in the investigation process and allow for additional learning to take place
  • Many serious incidents arise from a combination of individual and systemic failures or genuine error, often as a result of challenging working conditions and a lack of adequate resources. Doctors must feel able to reflect openly and truthfully to investigating teams without fear that this will be used against them, or learning will not take place
  • Investigation teams require dedicated, independent, trained personnel and expert clinical input. They need to be skilled in making judgements about the incident and also in supporting staff during a very difficult time. This, in turn, requires NHS organisations to provide funding and to release clinical staff to provide input into investigations. We envisage the forthcoming Healthcare Safety Investigation Body, established as an independent statutory body, as having a crucial role to play in setting a training framework for local investigation teams, as well as standards for how local investigations should be conducted
  • The framework should give guidance to NHS organisations about which incidents should be investigated, focusing on those where learning can take place, and ensuring that any learning is disseminated widely across the organisation and other organisations. Prolonged, multiple investigations of similar incidents are inefficient financially, and if managed inappropriately, can cause further distress for patients, their families and the clinical staff involved.

Read the response in full.

14 June 2018