The Parliamentary and Health Service Ombudsman has released what can only be described as a damning report into NHS complaint investigations.
What worries me is the ‘unconsious incompetence’ of NHS Complaints Managers
Over ninety per cent of NHS complaints managers said said they were confident an investigation would find out what was wrong. But the Ombudsman found that 40 per cent of NHS investigations were inadequate and Trusts had missed failings in 73 per cent of cases where the Ombudsman found them.
It is going to be essential that complaints managers receive this message in a way that is supportive and developmental – afterall, which of us would be engaged and motivated if we were told our work was this poor? The Report is silent on how the new Government body the Independent Patient Safety Investigation Service (IPSIS), to go live in April 2016, will ensure that we don’t simply get complaints managers leaving in droves.
There’s some shocking – but sadly not surprising – bad practice out there. But the good news is that this can all be addressed and improved. The scope to make significant and meaningful improvements in serious incident investigations is massive, when the benchmark is set so low. For example, in almost a fifth of investigations, medical records, statements and interviews were missing. There was a lack of structure, training and support around investigations. And people far too close to the parties involved were tasked with the investigation and it doesn’t matter whether they were impartial or not, what matters is the perception of impartiality, which was demonstrably lacking in some cases.
What you can expect to see tackled by IPSIS
The establishment of a national accredited training programme to support investigators- and hurrah for that. It’s essential that investigators know what is expected of them in detail, and have the training to get them to that standard – or not – if they are to feel equipped to carry out what is a difficult, emotional and responsible role like investigating a baby’s death. How could this ever have been left to untrained people?
You will also see guidance on more nuanced, but essential areas, like the impact of culture on investigators and their interviewees, how to show respect to everyone involved in the process; how to ensure you are given the time to investigate properly, and, inevitably, how to work in a way that is open and transparent. (Naturally these are all elements we cover in detail on our ILM endorsed programme…) You can also expect to see IPSIS clarify who should investigate and how independent of events they should be; broad requirements for specific evidence needed; how to ensure independent quality assurance; and general outcomes that ought to be achieved.
And if IPSIS doesn’t, then it will be another example of people in the Health sector knowing what the problems are, but not addressing them. And that, really, is no longer something we should tolerate.