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A poor quality investigation is no investigation at all

Medical negligence lawyer Despina Kavadas considers patient safety in light of a recent Government consultation

Intensive care unit
Despina is an experienced medical negligence solicitor who has specialised in this field since qualifying in 2002.
In its recent consultation on the ‘Future of NHS patient safety investigation’ the Government sought feedback and suggestions on how to revise the Serious Incident Framework with a view to improving the quality of NHS patient safety investigations.  

Patient safety investigations are intended to identify how and why patient safety incidents happen in the NHS. A standard set of procedures and analysis are used with an aim to identify areas for change and to develop recommendations which deliver safer care. 

They are usually triggered by a death or serious injury as a result of an identified adverse outcome.

As a clinical negligence lawyer it is often immediately clear to me, during our investigations into a case, how and why an official patient safety investigation report is inadequate. 

In one case, which involved an inpatient on a gastroenterology ward who committed suicide, a patient safety investigation was carried out by the hospital which concluded that the suicide was not predictable or preventable. 

However, at an inquest and in our investigations, evidence came out that suggested the deceased had suffered delirium, which had gone undiagnosed.

We know that a proper investigation needs time and expertise dedicated to it. On the basis of our experience we believe patient safety investigations should be carried out by trained teams with relevant expertise who are given sufficient resources to obtain all relevant information to carry out a full analysis. 

A full and complete analysis of a serious incident can ensure that any repeat errors and patterns can be recognised. 

In another of our cases a baby died as a consequence of medical staff at an NHS Trust giving her an overdose. 

The Hospital carried out its own investigation, but it was only after we were instructed by the family to carry out a clinical negligence investigation, it was revealed that their baby had died of a drug overdose which was avoidable and that there had been a previous death at the same trust as a result of an overdose of the same drug. 

An investigation must be thorough and the report it produces must be accurate. 

In another of our cases a patient died following sepsis, a serious investigation was carried out, but the report contained factual errors, including even the date and time of death. 

The family were not asked for their input into the investigation even though the trust was fully aware that they had been very concerned that their relative was deteriorating before they had died. Consequently, the factual errors were only identified after the investigation had been signed off and closed. 

Families want and need an investigation in which they have been fully involved

The information must also be disseminated more widely within the organisation, particularly where failings or concerns are identified, to ensure that there is learning and improvement is real and lives are saved.

If an investigation is closed without a thorough and proper analysis taking place, in our experience this results in a poor quality investigation and report and is not an effective use of time and resources, serving no useful purpose. 

A poor quality investigation and report will not ensure that the right lessons are learnt and therefore will not improve patient safety or prevent harm going forward, they must not be merely a box ticking exercise, leading to poor practice being allowed to continue.   

I hope that the Government takes on board the concerns and suggestions we have made in our response to their consultation, to ensure that lessons are learnt, repetition of harm is prevented and patients and families are listened to.

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