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Improving patient safety investigations

Medical negligence lawyer Nicola Wainwright discusses the Government's consultation on patient safety investigations, and Leigh Day's response to this

Very small baby in hospital
Nicola Wainwright is a partner in Leigh Day's clinical negligence team. She deals with a wide range of claims involving different types of negligence and injuries. Follow Nicola on Twitter @NicWwright
Earlier this year the Government requested views from a wide range of people on how and when the NHS should investigate and respond to Serious Incidents.

As we  act for patients who have been injured and families who have lost loved ones when something goes wrong in medical treatment, and hear first-hand about our clients’ lack of involvement in hospitals’ internal investigation processes, we have submitted our response to this consultation.

I’ve advised too many clients who only became aware of a serious incident investigation when they were presented with the report at the end of the investigation, when they made a complaint or, worse, when as part of the inquest or litigation process when complying with their duty of disclosure a health trust disclosed a report that the patient and family knew nothing about until then. 

In one case we acted for a family in an inquest into the death of their baby. Just days before the Inquest the trust disclosed a serious incident report which identified that the cause of death had been the misplacement of a TPN line (total parenteral nutrition – used to feed the baby intravenously) into the baby’s lungs. The family had been completely unaware of that error or that an investigation had been carried out.  

I do not understand how the NHS or other healthcare bodies can consider an  investigation a full and thorough inquiry if the patient or family are not involved from the outset. 

It goes without saying that the lack of involvement is distressing for the patient and their family. They are presented with a ‘fait accompli’ and left feeling that they are not of significance, confused about what happened and with their questions unanswered. 

They believe that the truth is being hidden from them and they are being ‘fobbed off’. That causes upset, anger and resentment for patients and families who are already suffering. 

However, it is not only poor practice as far as the patients and families are concerned but I believe it means that real opportunities to learn from mistakes and improve patient safety are being missed.

It seems that in the vast majority of cases we deal with, the information that the patient and their family can provide to an investigation is not seen of value. 

However, not only is the patient the subject of the incident being investigated they or their family are also the most important witnesses to the events that led to the serious incident. 

Often, they can give first-hand information on what happened and the how. They can give an overview of all aspects of care, as they were involved throughout the incident, unlike most of the witnesses, who can only comment on their individual role and not what happened on the shift before, or when they were busy with another patient or what the junior doctor said during the ward round. 

Their perspective will be different to that of medical staff but that does not mean it should not be considered of equal value.  

Although not medically qualified they can provide information on where, in their view, care went wrong. 

In every single case we deal with, the patient or family offer information that is not contained within the medical records or subsequent hospital staff’s statements.

During our own thorough investigations into an incident, this unique insight informs both our, and our medical experts’, views on how the incident occurred and how it could have been avoided. 

When patients and families are not involved in hospital investigations this information is missed and the investigation reports are always poorer as a result.

In our submission to the Government we make clear that one way in which patient safety can be improved is by ensuring that a patient or family are fully involved whenever a patient safety investigation is undertaken and that  a detailed account of events is obtained from them and carefully considered alongside the accounts of the staff involved.

Families and patients deserve nothing less than being heard when things go wrong.

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