Examining the internal complaints review process for the NHS, Parliamentary and Health Service Ombudsman Julie Mellor said that many distraught families were “met with a wall of silence” when they try to uncover why their loved one died or was harmed.
Mellor said that a wide-ranging review on the quality of NHS investigations into complaints found they are “simply not good enough”.
This meant people often had to the ombudsman to resolve the complaint, and overall it had investigated 536 cases about potentially avoidable deaths since January, and upheld complaints around half of these.
In nearly three-quarters of the cases into avoidable death and harm where the ombudsman found clear failings, the hospitals’ own investigations into the incidents found none.
In over half of the NHS investigations where a clinician reviewed what had happened, that clinician was not independent of the events at the centre of the complaint.
The ombudsman noted one occasion where the case of a baby girl who was left with permanent brain damage due to errors with a blood transfusion was investigated by a close colleague of the paediatrician in charge the day the mistake was made. The child’s parents also had to wait three years for the investigation to conclude.
Even where failings were identified, 36% did not find out why they had happened, despite 91% of NHS complaint managers claiming they were confident they could find out.
The review also highlighted that when hospital trusts find care failings, they do not always take action to prevent making the same mistakes again.
She called on the NHS to introduce an accredited training programme for staff carrying out investigations “so the public can be confident that when someone is needlessly harmed it has been thoroughly investigated” and action is taken to stop it happening to someone else.
Responding to the report, Neil Churchill, NHS England’s director for improving patient experience said that when people make complaints they expect it to be taken seriously. The best way to improve care is to listen to what patients and their families say, he added.
“Good quality, timely and consistent investigations are vital and the NHS continues to work hard to ensure patients feel confident raising issues or concerns.”
