Over the past two months, the House of Commons Public Administration Select Committee have been has been conducting an inquiry into clinical investigation and complaints in the NHS.
The inquiry was prompted by paper published in the Journal of the Royal Society of Medicine by colleagues Dr. Carl Macrae and Professor Charles Vincent, who present a compelling argument for the establishment of an independent patient safety investigation branch.
In partnership with the Clinical Human Factors Group, I’ve been supporting a small group of informed citizens with personal experience of avoidable harm in healthcare to put their case to the Select Committee and to argue their position to members of the parliament and their advisors. Our full submission strongly supports the Macrae & Vincent thesis.
In healthcare, processes for complaints and those for safety investigation and learning are often conflated. We argue that it is critically important to separate these fundamentally different processes for a “just culture” to be established. The negative, adversarial and ultimately punitive framing created by the dominance of a complaints based approach to avoidable harm is highly prejudicial. It simply adds to the culture of fear and denial for all and prevents effective learning.
As James Titcombe, a patient safety campaigner and core member of the group explains “In our view it should never be necessary for citizens to have to complain for proper investigation of avoidable harm to take place. If a complaint is the trigger for the identification and investigation of avoidable harm, the system is already failing”
The Select Committee is expected to report before the middle of March 2015