Once again, the Health Service Ombudsman has found that 40% of complaints made against NHS employees are not investigated properly. This comes in the wake of headlines that Southern Health Foundation Trust failed to investigate over 1,000 unexpected deaths. The report emphasised the need for trusts to find out why failings happened in the first place rather than carrying out cursory investigations that simply tick the box but otherwise do no good.
The Ombudsman’s report found the following information.
- In almost three quarters (73%) of cases where the Parliamentary and Health Service Ombudsman had found clear breaches and failings, hospitals had claimed in their own investigations of the same incident that they hadn't found anything wrong with their processes or actions.
- In almost half the cases of NHS investigations into complaints about avoidable harm and death the investigator is not sufficiently removed from the investigation and is not therefore sufficiently impartial
- In two thirds of the cases reviewed hospitals did not correctly identify incidents of avoidable harm cases as serious incidents, so they were not properly investigated.
- In 36% of NHS investigations which recorded failings the investigator did not find out why they had happened, though 91% of NHS complaint managers asserted that they are confident they could find out answers.
It also found that in almost 20% of investigations, statements and interview notes were missing, and that there is a lack of structure, training and support around investigations. One example involved a baby who suffered brain damage after a blood transfusion, where the investigation was carried out by a close colleague of the pediatrician in charge that day.
It’s a pretty damming report – and the worst of it is, these findings are not new. It’s time the NHS grasped its responsibilities far more firmly for everyone’s sake.
In any organisation, managers need to understand how to conduct an investigation. There will always be times when it is tempting to sweep a problem under the carpet, but that can put you at legal risk in the short-term if someone complains, and at risk of continued under performance in the long-term.
All managers should have training in the process of carrying out an investigation, as well as training and practice in the skills needed. Some investigations are quick and easy and need very little data to establish the facts. Some are extremely complicated and take several cycles of investigation to drill down to get to the facts. Investigators must learn how to probe and test data and not assume anything. Human beings naturally make assumptions when they talk, so ensure they stick to the absolute facts and double check wherever possible. If you have sensitive issues such as services for children or vulnerable people, you may need or decide to appoint someone as the designated officer for allegations relating to their treatment. This person must have at least an element of separation from those they are likely to investigate. The answers to questions often lead to more questions. It can be helpful to have a third party review the investigation report you draft as you go along to help you identify gaps in information.
The public sector tends to require a higher level of accountability than many private organisations (which can use flatter structures). However the taller structure in the NHS seems to have caused empowerment to carry out investigations to be held at the top, and those on the ground who want to investigate properly not being able to spread their skills and approach to others.
Things go wrong and when they do they must be properly and fully investigated. It is not only to assess the cause of mistakes but to enable organisations to take corrective measures for the future. It’s an essential process in any organisation.
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