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A review into the quality of NHS complaints investigations where serious or avoidable harm has been alleged

About complaints investigations, serious incidents and patient safety incidents

More than 80% of the complaints we receive are about NHS care and treatment, many involving avoidable harm.

Avoidable harm spans everything from minor to moderate harm, to unexpected or avoidable death and incidents that may cause widespread public concern resulting in a loss of confidence in healthcare services. Where the consequences of these failures to patients, families and carers, staff or organisations are so significant or the potential for learning is great, cases should be investigated as serious incidents1.

Generally, the complaints we see are about incidents of avoidable harm. These could be classed as patient safety incidents; cases where minor or moderate harm has occurred. Four out of five of the cases we reviewed were investigated as patient safety incidents as opposed to serious incidents.

As an Ombudsman's service, we believe that whether or not the event was significant enough to warrant being labelled a serious incident or a patient safety incident, people have a right to know that their complaint has been taken seriously and investigated thoroughly. Indeed, we expect trusts to be measuring and improving people's experience of complaining by using My Expectations2 when assessing the performance of their complaints service and to what extent this is meeting the needs of the public.

How we approached this

We reviewed 150 NHS complaints investigations where avoidable harm or death was alleged. We were interested to learn about the quality of complaints investigations; did these NHS investigations get to the root cause? Were the findings evidence based? We also spoke to six different trusts; we wanted to know what the challenges were to conducting these types of investigation and where there might be opportunities to improve the system. Finally, we surveyed over 170 NHS complaints managers to provide additional insight into the issues and brought together an advisory group to test our findings.


1 Serious incidents are defined as "unexpected or avoidable death, unexpected or avoidable injury resulting in serious harm - including those where the injury required treatment to prevent death or serious harm, abuse, Never Events, incidents that prevent (or threaten to prevent) an organisation's ability to continue to deliver an acceptable quality of healthcare services and incidents that cause widespread public concern resulting in a loss of confidence in healthcare services." NHS England (March 2015) Serious Incident Framework

2 PHSO (Nov 2014) My Expectations: a user-led vision for raising concerns and complaints