Learning from mistakes and effective serious incident investigation16/10/17
Serious incident (SI) investigations are a critical post incident analysis tool. A key report published last month by NHS Resolution - Five years of cerebral palsy claims’- analysed 50 obstetric claims which occurred between 2012 and 2016.In addition to identifying a need for further staff training (also a theme of the NHS Litigation Authority’s 2012 report and the recent & RCOG Each Baby Counts report) it highlighted the need for improved SI investigations with greater involvement of patients as well as staff.
Key findings of NHS Resolution study
- Evidence of poor quality SI investigations at local level. A working party is proposed to discuss the creation of a national training programme for SI investigators.
- The most common theme was foetal heart rate monitoring errors and underlying causes were often systemic. There is a need for further staff training, particularly in CTG interpretation and breech birth simulation.
- The effectiveness of training should be monitored by on-going review of clinical outcomes against competencies.
- Informed consent was not evident in all 50 of the claims reviewed. Notes simply stating “risks discussed” are insufficient.
How can SI investigations be more effective?
The report considered the following areas for improvement:
The report identifies the important role to be played by women and their families and recommends that investigations are not closed unless they have been actively involved throughout the process. Also staff involved in the investigation need better emotional support.
Root cause analysis
SI investigations often focused too heavily on individuals, rather than systems. Why the incident happened or was allowed to happen was often missing. Frequently it was replaced by a description of the incident and a detailed analysis of what happened.
Where guidelines or policy issues were considered a contributory factor, there was often no explanation as to why there had been non-compliance. Too great a focus on individuals without identifying why the errors occurred meant that system failures remain undetected.
To be effective in preventing future harm, SI action plans need to focus on systemic changes. An action plan should not focus on simply completing tasks such as recommending staff follow current guidelines. Why the guideline was not followed is at the crux of preventing a similar incident occurring in future. Does the guideline need updating? Is it easily accessible at all times? Is there consistency of application between hospital sites?
How can Capsticks help?
Capsticks were able to work with NHS Resolution in producing both the recent “Five Years of cerebral palsy claims” report as well as the previous seminal study “Ten Years of Maternity Claims”.
Based on our experience of claims and risk management we can assist healthcare organisations with completing SI investigations as well as training for staff on root cause analysis. We have also supported health providers by acting as the Independent Lead Investigator in Level 2 investigations for serious incidents where external review is considered necessary.