Shortly before Christmas, Parliament’s Public Administration Select Committee announced an inquiry into how incidents of clinical failure in the NHS are investigated – and how subsequent complaints are handled. The purpose of the Inquiry, which is ongoing at the time of writing, is to see whether some ‘incidents’ could be investigated immediately, so that facts and evidence could be established early on. This would happen regardless of whether a complaint has been made. The Committee would like to reduce the need for complaints to go to the Parliamentary and Health Services Ombudsman (PHSO), who is the final step in the complaints system.

In response to a call for evidence from the Committee, we used our Facebook page to ask parents about their experiences in this area. The deadline to produce the submission meant we could only give parents a short time to get in touch. Nevertheless, we received a high number of responses and were able to use parents’ own words to illustrate the problems with the current system. You can read Sands’ full submission, together with the other written submissions, at

In summary, we said that parents whose baby has died want acknowledgement of their concerns, an open and honest explanation of what has happened, an apology and a commitment to ensuring that lessons are learned and improvements made. We made the point that parents can feel patronised, and that their grief is sometimes used as a reason to discount or ignore their concerns. And we highlighted issues around communication – how it is sometimes insensitive and inaccurate, and said that parents’ frustrations led to them making complaints or taking legal action.

In addition to written evidence, the Inquiry has now heard oral evidence from expert organisations and individuals, including Katherine Murphy (Chief Executive, Patients Association), Katherine Rake (CEO, Healthwatch England) and Professor Sir Mike Richards (Chief Inspector of Hospitals, Care Quality Commission). Their views were thoughtful and interesting, and strongly supportive of a simpler easier approach to investigating when something goes wrong and learning lessons.

Professor Brian Toft, who is Professor of Patient Safety, Coventry University, told the Committee that one way of keeping down the numbers of ‘incidents’ going through a simpler system would be to “ensure that the recommendations made from investigations are actually implemented across the NHS.” He illustrated the problem by talking about inadequate fetal monitoring and stillbirth.

A few years ago, I did an investigation on some stillbirths at a hospital and I made my recommendations and gave my conclusions. Some weeks later, I read a paper from 1991 and I found the same thing. This is what I found when I did it. I said: ‘There appeared to have been inadequate foetal monitoring. There appeared to have been a lack of involvement by senior staff. Medical records were not as robust as they might have been. Some women had been ignored and had been given too little information.’ By the way, this was published in The Obstetrician & Gynaecologist in 2005. The British Journal of Obstetrics and Gynaecology in 1991 had this to say: ‘The review’s main criticisms were of inadequate foetal monitoring, lack of involvement of senior staff and inadequate records. Women had complained of being ignored and given too little information.’ There was a gap between 1991 and 2004, but the same problem was arising. If they had put in place the recommendations from that report in 1991, I might not have had to make my report in 2004.

Professor Brian Toft, Professor of Patient Safety, Coventry University
Oral Evidence to the PASC Inquiry on NHS Complaints and Clinical Failure, Feb 2015


We hope that the Committee will propose a workable and effective way for the NHS to learn and improve when things go wrong. Following a final evidence session with the Secretary of State for Health, the Committee will produce its final report in mid-March.

Written submissions are here.

The transcripts of the oral evidence can be found here and here. 

You can watch the oral evidence sessions here.