#JusticeforLB responds to investigating clinical incidents in the NHS
The PASC Committee report
Investigating clinical incidents in the NHS is published today by the Public Administration Select Committee of the House of Commons. The report makes a number of recommendations to improve the speed and success of investigating things that go wrong in hospitals.
MPs from all parties listened to evidence from lots of experts and agreed that at the moment investigations are not fair and are too slow. They focus on protecting reputations, trying to find who to blame, and avoiding financial liability, rather than on learning and trying to ensure it never happens again.
The person who chaired the committee, Bernard Jenkin, said for years it had been “evident that the NHS has urgent need of a simpler and more trusted system”.
It is almost two years since LB died, an entirely preventable death, while in the ‘care’ of Southern Health NHS Foundation Trust. LB’s family, friends and a growing network of people who refuse to accept that learning disabled people are less than fully human, have campaigned ever since to establish what happened to LB, what the learning from it is, and to try to stop this treatment of particular people.
The overwhelming response of those who should be accountable for LB’s death is one of repeated denial and defensiveness, of painting LB’s mother as problematic and difficult, of suggesting the campaign for Justice is accountable for the problems within the Trust. There appears no learning about the actions that led to LB’s death and little regard for the impact of the Trust’s actions on a bereaved family since.
Nationally, the lack of accountability and oversight, the continual hand-wringing of well intentioned politicians and system leaders, only intensifies the pain and distress caused by the kamikaze leadership at a local level.
It appears to us that ‘lessons learned’ has become some sort of code for ‘move on now, stop making a fuss, there’s nothing to see here, we’re in the clear’.
What the committee recommends
The Commons PASC report shows that there are lots of things wrong with the current way that investigations are conducted in the NHS. This means that they are failing patients, their families and NHS staff.
Currently there is no systematic and independent process for investigating incidents and learning from the most serious clinical failures. There is also no one person or organisation responsible and accountable for the quality of clinical investigations, or for ensuring ‘lessons learned’ are actually learned and used to make improvements in safety.
This has to improve.
The committee recommend establishing a national independent patient safety investigation body, supported by legislation, and that the government should do this as soon as possible. It must provide three things:
- A safe space: so patients and staff can talk freely about what has gone wrong without worrying that unfair things will happen to them
- It must be independent of providers, commissioners and regulators: so it can investigate the role of all parties and be able to say if the system as a whole may have contributed to what happened
- Transparency and accountability: to drive learning and improvement it must have the power to publish its reports and to disseminate its recommendations.
The committee think that investigations should be conducted locally, but at the moment local resolution is often too slow, too conflicted, too defensive and of poor quality. To improve this the relevant provisions of the Coroners and Justice Act 2009 should be implemented. This will create the post of Independent Medical Examiner in every local area. There should be one appointed for every Clinical Commissioning Group, to examine hospital deaths, to keep families of the deceased informed, and to alert the coroner to cases of concern.
The JusticeforLB response to these recommendations
Trying to get #JusticeforLB has felt like walking through a quagmire of stinking, hurtful and mis-focused NHS processes. From the very start Southern Health NHSFT have tried to shirk responsibility, attempting to dismiss LB’s death (he drowned in a bath) as natural causes.
His family, with no experience of how the process works, have relentlessly sought to ensure care is improved for other learning disabled people, while grieving for a much loved young man and having to construct a future without him. They have been subjected to spin, derision and incompetence at every step of the process; while professionals use public money to protect their reputations and avoid taking responsibility, they have to fundraise for legal support and campaign to try and get the most basic answers.
The recommendations from the committee are like a breathe of fresh, spring air and we hope that the government move quickly to progress them. We also suggest the government considers including a mechanism within this body to review Trusts’ use of legal representation in the coronial process.