• Regulator says current incident investigation approach is inconsistent and prevents learning
  • Some organisations are using incident reporting as a performance management tool
  • Trusts could be required to have dedicated resources, training and standards for investigation staff

NHS trusts could be experiencing “investigation fatigue” because they are using incident investigations as a tool for performance management instead of a way to learn from mistakes, NHS Improvement has warned.

The regulator has identified weaknesses in the way some organisations are investigating errors. It plans to revamp the serious incident framework as part of a consultation being launched today.

The framework, last updated in 2015, describes how errors in the NHS should be identified, reported and investigated.

After a review of incidents, NHSI said there was “compelling evidence from patients, families, carers and staff [which] revealed weaknesses in the way NHS organisations investigate, communicate and learn when things go wrong”.

In the consultation document, NHSI said some providers were using serious incident reporting mechanisms as a performance management tool, which undermined learning and improvement.

It said: “When systems become aware of a new risk or want assurance about potentially high profile risks, the tendency is to mandate the reporting of those incidents as serious incidents and to use that information to track performance.

“Currently, some investigations are being mandated regardless of circumstances; time is spent investigating very similar incidents which fail to generate new learning. This overloads the system and can result in investigation fatigue.

“We would like to consider whether resources could be used more effectively by being more selective; that is, prioritising incidents that require full investigation, investigating them to a high standard and implementing the actions informed by this to prevent future patient harm.”

Reforms to the system of incident investigation could include new requirements on providers for how they approach incidents, who they employ to investigate mistakes, and the support and involvement of families, patients and staff.

The regulator said evidence going back decades showed individuals were rarely to blame for mistakes and punishing staff for errors did not lead to them happening less. It warned that “failure to support and involve staff allows a ‘blame culture’ to develop. This is reinforced when investigation reports infer that error is the fault of individuals by recommending periods of self-reflection or retraining to prevent incidents recurring. Although this may not be intentional, blame is directed at the individuals involved.”

Suggestions made by NHSI in the consultation document included:

  • Requiring organisations to have dedicated staff to support workers after an incident.
  • Providing families with standardised information and feedback.
  • Requiring a formal assessment of whether an individual intended harm, acted recklessly or has health issues before action is taken against them.
  • A requirement for decision makers to demonstrate training and understanding of “just accountability”.
  • Setting minimum resource requirements for an investigation team.
  • Requiring a national agreed minimum number of investigations for each organisation.
  • Making trusts invest in specific teams with expertise in incident investigation.

The consultation is open until 12 June.