Annex A: Our approach and the evidence we gathered
We gathered evidence about the quality of NHS investigations through four strands of work: a review, a survey, visits to trusts, and an advisory panel.
In January 2015 we completed an initial review of 150 of our cases that involved a complaint about avoidable harm or death. The aim was to establish whether trusts’ own handling and investigation of these types of cases are adequate to identify and deal with failings in care or a serious incident. Our investigators answered a series of questions about the quality of the NHS’ original complaint investigations, and the evidence that the trusts had relied upon in coming to their decisions.
In March 2015, we sent a survey about the investigation processes in relation to complaints about patient safety incident to 171 complaints managers in all acute trusts in England. The purpose of the survey was to understand their processes, and gain insight into best practices and areas for improvement. We asked closed questions and gave staff the opportunity to provide qualitative comments. The survey was anonymous. There were 104 responses after a three-week period. This equates to a response rate of 61%.
We visited acute trusts across the country, including small trusts, large trusts, trusts that had been performing well, and also those that had recently been in special measures. We asked the trusts questions about how they investigate allegations of a patient safety incident and how their complaints process is set up to investigate and learn from complaints. We spoke to a wide variety of staff including directors of nursing, complaints managers, complaints staff, divisional leads, and governance leads. We used the information from these visits to validate and add depth and context to the information that we obtained from the survey and the review. We also looked to find examples of good practice.
Once we had gathered evidence from the review, the survey and the visits, we convened an advisory group. The advisory group was made up of organisations and individuals with a special interest in patient safety incident investigations. We discussed our findings with the advisory group, whether what we found fits with their experience and how our work fits into the wider landscape. All members of the advisory group said that our evidence resonated with their experience.
You can read a summary of the evidence we gathered in Annexes B to E of this report.
After we had collated all the evidence, we analysed it against the existing applicable standards: the Ombudsman’s Principles of Good Administration and Good Complaint Handling, My Expectations, the Duty of Candour, and the Complaints Regulations. We considered whether what we had found suggested that the NHS was falling short of those standards when conducting a patient safety investigation following a complaint. We looked at whether the culture, systems and processes that were in place were robust enough to allow those standards to be met.