Regulator calls for 'step change' in incident investigations

The regulator said national bodies should cooperate to bring this about, and has passed its findings to Keith Conradi, the first chief investigator of the newly created Healthcare Safety Investigation Branch.

It will inform his work to develop an “exemplar model” of local incident investigations, which is one of his first big priorities.

The CQC’s review, which looked at serious incident investigations in acute trusts, found wide variations in protocol continue to exist.

It said its findings ”provide further evidence of the need for a step change in the way that serious incidents are investigated and managed in the NHS”.

It continued: “The development of the new Healthcare Safety Investigation Branch and the move of the National Patient Safety team from NHS England to NHS Improvement provides a timely opportunity for us to come together to develop a shared definition of good practice and agree how we will work together to support and encourage improvement.”

A CQC spokesman said the review findings had been shared with Mr Conradi to inform his work on the “exemplar model”.

The CQC found trusts were routinely failing to involve patients and staff in the investigation process.

The regulator reviewed 74 investigation reports from 24 acute trusts. Of these, only nine (12 per cent) clearly indicated any involvement of the patient or family in the investigation, with just 36 per cent showing that the family concerned had been offered a chance to discuss the findings.

Similarly, more than 60 per cent of reports showed no evidence that staff involved in the serious incident had been interviewed.

The CQC also found that a third of the investigations did not clearly meet the criteria for a full investigation under NHS England’s serious incident framework.

Its review said: “We concluded that some of the incidents we reviewed would have benefitted from alternative approaches, using less complex but more efficient ways to address the needs of the patient(s) and to identify any mitigating actions that could prevent the incidents happening again.”

The CQC said it wanted to see an approach which prioritised serious failures, and develops alternative approaches to learning from other incidents. It has also recommended investigations focus on identifying the underlying causes of failures rather than on staff behaviour.

Shortcomings in NHS incident investigations have been repeatedly criticised, including by MPs on the public administration select committee in March, the Parliamentary and Health Service Ombudsman, and previously by the Morecambe Bay Inquiry by Bill Kirkup and the Mid Staffordshire Public inquiry.

In response to this criticism health secretary Jeremy Hunt has said the NHS should improve its response to serious incidents, and established the HSIB to lead on a new approach.