National Ombudsmen
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Ombudsman comments on parliamentary report into avoidable deaths in the NHS

Commenting on the report by the Public Administration and Constitutional Affairs Committee called Will the NHS never learn? Follow-up to PHSO report ‘Learning from Mistakes’ on the NHS in England, published yesterday.

Parliamentary and Health Service Ombudsman Julie Mellor said:

We know from our casework that families who complain to the NHS want lessons to be learnt so that future mistakes are avoided.

‘The NHS still has a long way to go to provide staff with the relevant skills to carry out fair, high-quality investigations into avoidable harm.

‘The government and NHS leaders must commit to providing training, national standards and accountability for the NHS, to make it safer for all.’

Background information

In 2016 we completed 835 investigations into potential avoidable deaths in the NHS in England. We fully or partly upheld 368 of these. These statistics are from 1 January 2016 to 1 January 2017.

In our 2015 review of NHS investigations into serious harm, we found that nearly three quarters of hospital investigations into complaints about avoidable harm and death claimed there were no failings in the care given, despite our investigations of the same incidents uncovering serious failings.

In our 2016 Learning from Mistakes report, we identified wider systemic lessons for the NHS, focusing on the need for the NHS to move from a culture of fear over mistakes to one that embraces learning and improves the competence and co-ordination of investigations.


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