Independent investigations – an unoptimised function for learning

Independent investigations – an unoptimised function for learning

Kate Jury, Managing Partner

Independent investigations into healthcare incidents are a vital part of patient safety.

Not only do they have the ability to safely surface the facts to improve healthcare services. But independent investigations also provide families with vital answers that they need about the care they or a loved one received.

Beyond this, independent investigations regularly feed into coronial processes, police investigations, inquests and inquiries. They have also been central to mental health homicide investigations, domestic homicide investigations and death in custody reviews for many years.

Questions about ‘what actually changes’ following such investigations are reasonable and, like the proliferation of learning from Prevention of Future Death Reports, much more could be done to ensure that learning is shared between healthcare providers. Indeed, this would not only optimise learning opportunities but also deliver the most value for the public purse.

All findings are not the same…

There is often an assumption that independent investigations repeatedly find the same things and, whilst this is sadly the case sometimes, this assumption should also be challenged. No organisation is the same, no system is the same and no culture or process is the same and therefore, assuming that findings are the same (and by implication minimising them) is reductive and potentially introduces risk.

Independent investigations will indeed find shared characteristics, for example, investigations into mental health care and treatment will likely often feature one or more of the following:

1. Issues with communication and documentation (evident in around 90% of cases)
2. High community caseloads and discharging patients in their absence
3. Lack of risk identification and risk planning
4. Inter-agency working issues
5. Failing to listen to the nearest relative where concerns are escalating
6. Poor or ineffective internal investigations which both fail to identify causes (including system issues), and which fail to properly involve families.

Many more specific findings found through investigations might include the identification of closed cultures, failing to recognise other vulnerable family members (particularly the vulnerability of young siblings and older age carers), over-diagnosing and over-medicating young people creating iatrogenic harms, and failing to follow-up on safety critical audit points around ligatures (for example), all of which contributed to a catastrophic outcome.

Central to the lack of change

Findings which are consistent across many organisations, do not mean that the independent investigation in itself was not necessary. But high consistency findings do probably mean:

• This is a regular and repetitive task with a consistent error or neglect rate (for example note taking)
• A gap been work as imagined and work as done
• This is a task which is often cut short due to capacity
• There was failure to learn from the event and close the loop on learning through an audit
• Governance issues have prevented or prohibited change, this can include culture
• There was insufficient sharing across other organisations and insufficient recognition and relevance in relation to one’s own practice
• Recommendations were poorly articulated

How to share for the best impact

A problem in sharing learning is that there is no central repository for trusts to access independent investigation findings. A key issue here is the increasingly tight controls (rightly so) on the availability of any personal information in the public domain, rightly so. It is becoming more and more rare to see whole investigation reports in the public domain but this in turn means a limitation in sharing insights.

Learning bulletins are key (short and anonymised summaries) which help staff to learn and reflect upon their own practice –are available – but not routinely, and so when staff are seeking out this kind of information, it is often reliant upon them knowing how and where to look. It should be much easier to search against subject relevance to support learning and professional practice.

Arguably, the findings of independent investigations, if well pooled and categorised should be able to offer as much, if not more, learning than a public inquiry. Particularly, this vital source data can be used and aggregated into a bank of primary research.

The repetition of findings in independent investigations is not really the problem, the inability to share those findings, along with recommendations which have broader connective relevance, is.