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Calls for Independent Investigator of Clinical Accidents

The UK Parliament’s Public Administration Select Committee (PASC) has published a report calling for a new national independent patient safety investigation body to be established in England.

According to the Secretary of State for Health, there are an estimated 12,000 avoidable hospital deaths every year, and more than 10,000 serious incidents are reported to NHS England annually. There were 338 recorded "never events" (such as wrong site surgery) in 2013-14 and NHS England received 174,872 written complaints. The NHS Litigation Authority’s latest estimate of clinical negligence liabilities is apparently £26.1 billion.

The huge numbers involved in the overall work of the NHS—15.8 million admissions to hospitals and 19.2 million A&E attendances in England the year to November 2014—put those figures in context, but PASC says that the overwhelming response received to its inquiry is an indication of the devastating impact of clinical failures when things do go wrong.

The report states that patients and NHS staff deserve to have clinical incidents investigated immediately at a local level, so that facts and evidence are established early, without the need to find blame, and regardless of whether a complaint has been raised. The Committee says there also needs to be a clear effective central system for disseminating the lessons learned from local incidents across the NHS nationally.

“Ever since the MidStaffs hospital crisis and the Francis Report, it has been evident that the NHS has urgent need of a simpler and more trusted system for clinical incident investigation at both local and national level,” commented Bernard Jenkin MP, Chair of the Committee. “This was again confirmed by the Kirkup report into the Morecombe Bay baby deaths.”

“There needs to be investigative capacity so that facts and evidence can be established early, without the need to find blame, and regardless of whether a complaint has been raised,” he added. “Our proposals for a new investigatory body will help transform the safety culture of the NHS and help to raise standards right across the NHS. This proposal is widely supported and it should be taken up early in the new Parliament.”

Contains Parliamentary information licensed under the Open Parliament Licence v3.0.

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