National Ombudsmen
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Ombudsman calls for culture change in how NHS investigates avoidable deaths

A report published today calls for a no-blame culture in which leaders and staff in every NHS organisation feel confident to openly investigate complaints, in order to learn from them and improve patient safety. 

The report, Learning from Mistakes, published by the Parliamentary and Health Service Ombudsman said that the NHS needs to build a culture which gives staff and organisations the confidence to find out if and why something went wrong so that they can learn from it.

An investigation by the Ombudsman service into the death of Sam Morrish, published in 2014, focused on the care and treatment he received and found that his death was avoidable. It fully upheld the family’s complaint and the organisations complained about have taken action to put things right.

Today’s report looks into how the NHS failed to uncover that his death was avoidable, which has lessons for the whole of the NHS in how it investigates such cases. It reveals how those involved in the local NHS investigations were not sufficiently trained, aware of the relevant guidelines or sufficiently independent of the facts complained about.

The report highlights how the local NHS investigation processes were not fit for purpose, they were not sufficiently independent, inquisitive, open or transparent, properly focused on learning, or able to span organisational and hierarchical barriers, and they excluded the family and junior staff in the process.

Parliamentary and Health Service Ombudsman Julie Mellor said:

‘We hope that this case acts as a wake-call up for NHS leaders to support a no-blame culture in which leaders and staff in every NHS organisation feel confident  to find out if and why something went wrong and to learn from it.

‘The new Health Safety Investigation Branch (HSIB) is a step in the right direction, but will only investigate a small number of cases.

‘We want to see a national accredited training programme for people carrying out NHS investigations and for this to include clarity about independence and accountability.’

The findings in this report echo the Ombudsman service’s recent review into the Quality of NHS investigations, published last December, which found that 40 per cent of NHS investigations were not adequate at finding what had happened. Since January 2016, a further 436 complaints about potential avoidable death have been investigated by the Ombudsman service, of which 200 have been partly or fully upheld.

Sam’s father, Scott Morrish, said:

‘I hope that this report leads to rapid change in the culture of the NHS, so that mistakes can be recognised, investigated and learnt from. Anything short of that isn’t safe for patients and isn’t fair to NHS staff.

‘I hope that no other family has to go what we have been through. Sam’s death was avoidable, and the NHS should have given us the answers we needed soon after he died, to enable improvements to be made.’

Today’s report highlights how all NHS organisations can learn from mistakes, as well as the Parliamentary and Health Service Ombudsman. The report highlights how the family has contributed to how the Ombudsman service uses its casework to help NHS leaders drive through system improvements.

The report welcomes the creation of the Health Safety Investigation Branch (HSIB). However it highlights the importance of conducting good local NHS investigations, as HSIB will only investigate a small number of cases. This means that many families will still be reliant on local NHS investigations to get answers and to help ensure lessons are learnt.

The Parliamentary and Health Service Ombudsman investigates complaints which have failed to be resolved by the NHS locally. 

Notes to editors

To view the Ombudsman’s service’s Review into the quality of NHS complaints investigations where serious or avoidable harm has been alleged, published last December, click here.

To view the Ombudsman service’s first investigation report into the death of Sam Morrish, click here.


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