By: 20 February 2015
No need for patient safety investigation body

No need for patient safety investigation body

There is no need for a clinical accident investigation body to be established to investigate NHS complaints but there should be better coordination of existing systems to ensure lessons are learned from incidents, the Medical Defence Union, (MDU) has said.

The MDU made the comments in written evidence to the Public Administration Select Committee’s (PASC) inquiry into NHS complaints and clinical failure in England. The PASC is seeking views on the effectiveness of current procedures, as well as whether a new clinical accident investigation branch of the Department of Health should be established. The review is also seeking views on the current capacity of the Parliamentary and Health Service Ombudsman (PHSO) to manage and investigate clinical complaints and her ability to analyse and assess medical evidence.

Dr Michael Devlin, MDU Head of Professional Standards and Liaison, is due to appear before the PASC to give evidence on February 3rd. He said:

“We are concerned about the suggestion that yet another body should be introduced to look at patient safety. There are already numerous organisations with significant expertise who can investigate a patient safety incident and we think there is no need for an additional body. Rather than creating new and additional layers of regulation, reporting and oversight, NHS staff should receive more support and encouragement to learn from incidents and complaints within an open organisation culture. If individual staff know that what they say will be addressed in a fair and impartial way, there will be more of an incentive to share concerns.

“Organisations that can investigate an incident include the Care Quality Commission, the Medicines and Healthcare products Regulatory Agency, the Health and Safety Executive, the General Medical Council and the police NHS hospitals and GPs also routinely investigate patient safety incidents under local procedures, to establish what
happened and what can be learnt.

“Doctors also have a professional duty to be open and honest when something goes wrong and there is a statutory duty of candour on NHS hospitals, which will apply to general practices and private providers in England from 1 April 2015.

“We think there is a need for greater coordination between all the different bodies potentially involved in investigating a single clinical incident to ensure lessons are learned and the necessary changes are made if problems are identified. It’s really crucial that learning from incidents is shared within the wider NHS organisation, not just the individuals involved in the case, so that patient safety is improved.

“Patients also need to be provided with clear information about how to make a complaint, which organisation to go to and what will happen as a result.

“We have concerns about the capacity of the PHSO to take on yet more work in investigating complaints about clinical incidents. The PHSO is now investigating far more complaints than in the past. Unfortunately, this has led to delays in complaints handling and a deterioration in the quality of investigations, some of which were highlighted by the Patients Association in November 2014.”

Originally published on