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You will have seen the news reports of the inquiry into patient deaths of people in the care of Southern Health Foundation NHS Trust, (http://www.bbc.co.uk/news/health-35051845). The inquiry’s findings were obtained by the BBC, and we have yet to see the full report. One of the issues the BBC reported on was there seemed to be no proper system in place to learn lessons from the unexpected deaths of people with mental health problems and learning disabilities. There will be a lot more to learn when we see the full report published but meanwhile it’s worth looking at how we should learn lessons from serious incidents including the unexpected deaths of people in our care.
Seven Principles of Investigation
I’ve been having a look at the NHS latest guidance for learning from serious incidents. The National Framework for Reporting and Learning from Serious Incidents Requiring Investigation was revised in March 2015 and provides guidance for NHS organisations. You can access this guidance at: https://www.england.nhs.uk/patientsafety/wp-content/uploads/sites/32/2015/04/serious-incidnt-framwrk-upd2.pdf
The guidance includes seven principles covering how investigations should be conducted. I think these are very good principles that could be applied to any examination by health and social care staff when something has gone seriously wrong. I’ve listed the headings below with some comments as to what these are about:
- Being open: That’s about thinking about everybody who has been affected, learning lessons shouldn’t be a statistical exercise, it should be a thorough investigation that including families and friends, being open and honest with them, and giving support to those people affected.
- Preventative: This is about learning in an attempt to prevent similar occurrences happening again, perhaps by instituting some changes to practice.
- Objective: That may be about incidents being investigated by staff other than those directly involved in the incident – bring a fresh pair of eyes to the incident.
- Timely: Ensuring an investigation is thorough should not mean it is delayed.
- Systems approach: Following a systematic approach to investigation – to identify what went wrong, how it went wrong and why it went wrong.
- Proportionate: The more serious the incident, the more staff, time and resources should be devoted to investigating it
- Collaborative: Investigations should including working alongside other agencies who may have been involved in the person’s care.
The QCS Duty of Candour Policy and Procedure gives full guidance as to the investigation of serious incidents in your care home . Unfortunately, serious and untoward incidents do happen. It is vitally important we learn from them.