Call for New Body to Investigate Clinical Failures

Finding out those all important answers as to what happened following medical negligence is vitally important and for the majority of individuals, it is the principal reason in bringing a clinical negligence claim. Their main aim is for investigations to be completed into why the failings happened and for practice to be changed to ensure it never happens again. Writing a complaint to the Ombudsman can be a very time consuming and drawn out process. A recent report into this area has been carried out by MP’s which states that the NHS ombudsman has been "defensive and has caused pain by its reluctance to admit mistakes when investigating patients' complaints”.


The Public Administration Select Committee (PASC) in response to this report has called for a new independent body to investigate clinical failures before they reach the ombudsman. It is hoped to transform the safety culture of the NHS and help to raise standards across the NHS. The report suggests that the current systems are complicated, take too long and are preoccupied with blame and avoiding financial liability, something which many individuals experience when making a complaint to the Ombudsman.

Failings in Recent Years

The report comes at a time when there have been a number of failings in recent years. The chairman of the PASC provided his comments on this matter and said there had been an "urgent need for a simpler and more trusted system for investigating clinical failures in the wake of the Stafford and Morecambe Bay hospitals scandals”. The PASC said patients and NHS staff deserve to have clinical incidents "investigated immediately at a local level to establish facts and evidence, without the need to find blame, and regardless of whether a complaint has been raised". The PASC acknowledged that lessons need to be learned and procedures need to be changed to address these underlying difficulties with the current system.

There have been a number of discussions around this topic in recent months with a Patients' Rights charity commenting, at the end of last year, that it had “no confidence in the independent NHS ombudsman investigating individuals' complaints about the health service”. They said the “Parliamentary Health Service Ombudsman (PHSO) is the last resort for those who complain about poor care from the NHS, and individuals are not satisfied by the answers they get from the organisation which failed them”. The charity also commented that there are too many cases in which the Ombudsman had failed to carry out a proper investigation, they have made errors, and accepted incorrect versions of events. It seems the quality of a number of investigations falls far short of what patients, their families and NHS staff members are entitled to expect to receive. Individuals when sending their complaints to the NHS ombudsman wish to uncover the truth about what happened to them or a loved one and do so at a very difficult time in their life. It is therefore vital that there is a trusted and effective system in place for bringing the truth to light.

More than 12,000 Avoidable Deaths

This is an important step moving forward as the Department of Health estimates that there are more than 12,000 avoidable hospital deaths every year in the UK. The committee report notes that more than 10,000 serious incidents are reported to NHS England annually and the NHS England received 174,872 written complaints.

According to PASC the new national independent patient safety investigation body should meet the following criteria:

  1. Be transparent and accountable directly to Parliament.
  2. Offer a safe space with strong protections for patients and staff, so they can talk freely and without fear of reprisals about what has gone wrong.
  3. Be independent of providers, commissioners and regulators, and so able to investigate whether and how the system as a whole was instrumental in contributing to clinical failure. 
  4. Have the power to publish its reports and to disseminate its recommendations. It should be for the Care Quality Commission and other executive, regulatory and commissioning bodies to ensure they are implemented.
  5. Have its own substantial investigative capacity, so that it can lead by example, oversee local investigations and conduct its own investigations when necessary.

This proposed change is an important step in highlighting the current difficulties and the recognition that important changes need to be made in this area.