An independent national patient safety organisation to investigate clinical incidents in the NHS should be created immediately after the election, a committee of MPs has said.

The cross-party report by the Commons public administration committee also heavily criticised the Parliamentary Health Service Ombudsman for its “defensiveness and reluctance to admit mistakes”.

The committee said the ombudsman’s “failure to uncover the truth” caused families considerable “anguish and disquiet” and called for fundamental reform and culture change at the watchdog.

Health secretary Jeremy Hunt backed the creation of an independent patient safety investigation unit in his response to the University Hospitals of Morecambe Bay Foundation Trust inquiry earlier this month.

The Cabinet Office also launched a consultation this week on creating a new single public sector ombudsman with new powers and reformed rules for how it would operate.

The committee said the cost of a national patient safety body would be relatively small compared to the costs of clinical negligence and failure to investigate incidents properly.

It has been estimated that there are 12,000 avoidable hospital deaths every year, with more than 10,000 of the most serious incidents reported each year.

The MPs cited examples of the consequences for patients when mistakes happened, including one patient who needed to have a leg amputated after the accidental injection of disinfectant during a routine angiography at Doncaster Royal Infirmary in 2013.

The committee said the new patient safety body could help the NHS investigate incidents as well as spreading learning across the service. It said the quality of investigations fell short of what patients or staff should expect, describing the system as too complicated, taking too long and preoccupied with blame or avoiding financial costs.

It said the next health secretary should act immediately after the election to set up a body which would:

  • be transparent and accountable to Parliament;
  • offer strong protections for patients and staff to talk freely without fear of reprisal;
  • be independent of providers, commissioners and regulators to investigate how the whole system contributed to incidents; and
  • have the power to publish its reports and have its own investigative capacity.

The MPs said clear criteria would be needed to establish which incidents the body would investigate to prevent it being overwhelmed.

Bernard Jenkin, chair of the committee, said: “Ever since the [Mid Staffordshire] hospital crisis and the Francis report, it has been evident that the NHS has urgent need of a simpler and more trusted system for clinical incident investigation at both local and national level.

“This was again confirmed by the Kirkup report into the Morecombe Bay baby deaths.”

He added: “There needs to be investigative capacity so that facts and evidence can be established early, without the need to find blame, and regardless of whether a complaint has been raised. Our proposals for a new investigatory body will help transform the safety culture of the NHS and help to raise standards right across the NHS.

“We are calling on the secretary of state to start consulting on this proposal immediately after the election.”

Topics