Sands welcomes the report from the Public Administration Select Committee’s Inquiry ‘Investigating clinical incidents in the NHS’, published today (27.03.2105).

In late 2014 the 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 was to examine the current picture of complaints and investigations in the NHS, compare it with systems in other areas that carry out serious investigations, notably airline safety, and make recommendations to Parliament.

The report calls for a national independent patient safety investigation body and a new system of investigations to be established.

The Committee recommended that:

  • Patients, their families, clinicians and staff should be protected so that they can talk freely about what has gone wrong without fear of reprisals; for staff, this doesn’t mean that they remain immune from prosecution on the basis of the findings of an investigation.
  • The investigator should be independent of providers, commissioners and regulators, and so able to investigate whether and how the system as a whole contributed to clinical failure. Quality Commission, cover both NHS and independent health care providers.
  • For transparency and accountability, and to drive learning and improvement, the investigator must be able to publish its reports and to disseminate its findings and recommendations.

Sands submitted evidence of the current picture in the NHS for parents of babies who die, having asked bereaved parents for their experience.

A spokesperson for Sands said:

"We are pleased that the Committee considered all the evidence with care and recognised 'a grim picture of grief and anger caused by denial, defensiveness and evasion.'

"We support the conclusion of the Committee that there is a need for a new system to support “swift and effective” local clinical incident investigation by trained staff. The importance of independence, transparency and accountability, cited by the Committee as key elements of such a system, was highlighted by the bereaved parents who shared their experience via our submission. We trust that the Secretary of State for Health will prioritise the Committee’s recommendations after the general election, particularly in light of the recent Morecambe Bay Investigation Report, which called for clear standards in the investigation and reporting of serious incidents.

"Finally, we are pleased that the Committee has called for Human Factors and incident analysis to be incorporated into training for health professionals. By raising the standard of investigation when a baby dies and ensuring services have the mechanisms to learn and improve, we believe that babies’ lives will be saved.

"Sands thanks those parents who shared their experience for our submission to the Committee’s Inquiry."

The full report is available to read here