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​Improving the quality of investigations when things go wrong

How our casework makes a difference : improving the quality of investigations banner image

We reviewed the quality of NHS complaints investigations where serious or avoidable harm was alleged.

Our casework highlighted that families are being left without answers as hospitals across England aren’t investigating alleged avoidable harm and death properly. We have also found that there are missed opportunities for learning when things go wrong, and staff don’t feel supported and recognised in their investigatory roles.

In one case we investigated, it took three years for the parents of a brain-damaged baby to get a proper explanation of what happened following serious errors in a blood transfusion, adding to their distress. The trust acknowledged the investigation was a review of notes only, and that clinical staff had not been interviewed or asked to provide written statements.

Our thematic report triggered a follow-up inquiry by Parliament’s Public Administration and Constitutional Affairs Committee, which highlighted our recommendation to improve the quality of investigations through the training and accreditation of local investigators.

Our report has subsequently contributed to a consensus on the need to improve the capability and quality of local investigations, as reflected in reports from the Expert Advisory Group for the new Healthcare Safety Investigation Branch (HSIB), and the Care Quality Commission.

Read the full report: A review of the quality of NHS complaints investigations where serious or avoidable harm has been alleged.