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

Annex E: Advisory group - summary


In June 2015 we held a meeting with an advisory group to discuss our findings, how what we had found resonates with their experience, and how our work fits into the wider landscape. The advisory group was made up of organisations and individuals with a special interest in complaints investigations, patient safety incidents and serious incidents. The advisory group comprised Peter Walsh (Action Against Medical Accidents), Chloe Peacock (Healthwatch), Brian Toft (Coventry University), Denis Wilkins (CORESS), Donna Forsyth (NHS England), Nikki Pitt (Department of Health), Maria Dineen (Consequence UK), Carol Brennan (Queen Margaret University), Paula Mansell (Care Quality Commission) and Umesh Prabhu (Wrightington, Wigan and Leigh NHS Foundation Trust). Paula Mansell and Umesh Prabhu were unable to attend the advisory group meeting and therefore we met with them separately to capture their views. All members of the advisory group said that our evidence resonated with their experience.

Key areas

At the advisory group discussions, we identified key areas for improvement: those most in need of change; and those areas which, if changed, would have most impact on improving investigations.  We also identified that culture and leadership are crucial to improving the following areas:


The advisory group considered that it would be useful for investigators to have a skills and competency framework. 

Skills that were seen as important to such a framework include:

- Facilitation;

- Analytical;

- Project and multi-project management;

- Time management;

- Interviewing; 

- Research, including content mapping7 and affinity mapping8;

- Active oral and written communication, which is empathetic and;non-judgemental. 


The advisory group also considered that investigators should have enough seniority to carry things through, and have a sound knowledge of a range of investigation and human factors9 methodologies.

The group felt that training for investigators should be accredited, and those that provided the training should be able to show evidence of competency and compliance with national requirements in their training packages.

In addition, they felt that a senior level champion (a named person) in each trust, for example, a head of profession, at board level could oversee the training of staff conducting investigations.
The advisory group suggested that a buddying, leadership and mentorship pool within and across clinical care group communities could be developed to aid training and share experience.

Consistent process 

The advisory group felt that the patient and family that had made the complaint should be involved at every stage to manage expectations and to provide information for the investigation.  They also felt that the patient and/or family should be able to have access to a source of independent advice and support. 
They said that consideration should be given to standardising the investigation process across the NHS.  This may include alignment of complaints investigations into patient safety incidents and serious incidents investigations, so that all investigations are subject to the same process, albeit the size, complexity and terms of reference of the investigation could change. For this to happen, the advisory group said that the complaints team and governance may need to sit and work together.

The advisory group noted that the NPSA had developed an investigation template, but this is not used routinely.  It was hoped that the new clinical incident investigation unit (IPSIS) would consider how to make sure that a template is used consistently.  This may include considering how any template would match the skills and/or competencies of investigators, so that staff have the knowledge to use the template.

The advisory group also considered that commissioners could be involved in ensuring independence in the investigations process.  Clinical commissioning groups, or a group of trusts, could develop a pool of investigators who can share resources and reciprocate help by giving independent views.  Equally a group of people who would challenge the investigation process could be set up.

Learning and monitoring

The advisory group agreed that the term ‘learning’ needed to be clearly defined.

The theory of the use of legislation versus education to spread what is learned from complaints across the NHS was discussed. That is, do trusts need someone external to the system  to motivate and make changes happen (for example, legislation and/or policy changes backed up by penalties for non-compliance), or whether training,  empowering staff, and making changes to the culture would result in change. 

The group felt that the possible blocks to improving learning from complaints (both across and within trusts) were:

- 160+ trusts all approach this differently and they do not always talk to each other;

- Limitations on resources, although it was felt that a potential solution to this would be to involve the third (charitable) sector;

- They felt that there have been opportunities to build a more collaborative culture and it may not have happened because:

People are not always willing to share (in order to prevent bad press or the need to be the best independently);

There was a risk to organisations’ reputations;

People do not want to relinquish control;

People work in isolated groups;

There tends to be a coalition of the willing - those who would naturally engage with this do, and the remainder do not.

The advisory group considered leadership to be the key to a supportive learning environment by:

- Using a public forum to discuss patient safety incidents where staff can make public pledges;

- Involving staff in finding solutions;

- Working together;

- Listening to staff at all levels; and

- Encouraging staff at all levels to speak up, and bring down the hierarchy.

Many of the advisory group members thought that the solution, therefore, was to use the benefits of both legislation and encouraging collaboration and partnership. Together these methods may result in:

- Empowerment of clinical teams;

- Legislation and accountability as the backstop if individuals or organisations are unwilling to learn; and

- Harnessing  good practice and inviting people to tell and/or share their stories.

7 A tool used to map content to the needs of service users or the organisational goals.
8  A tool used to group information and ideas together according to them having a shared relationship. 
9  The process of understanding what factors will affect how people think, behave and act.