Commenting on the report by the Public Administration and Constitutional Affairs Committee (PACAC) called Will the NHS never learn? Follow-up to Parliamentary and Health Service Ombudsman (PHSO) report ‘Learning from Mistakes’ on the NHS in England, published on 31 January, the PHSO concluded that the NHS needs to learn lessons when things go wrong, especially by listening to relatives.
College President, Dr Suzy Lishman said:
"The College wholeheartedly agrees with this conclusion. However, the College is surprised that the report from the PACAC and the Ombudsman’s response did not put more emphasis on the potential of the reforms contained in the Coroners and Justice Act 2009. This legislation includes the introduction of a national system of medical examiners; independent senior doctors who will scrutinise every death that is not investigated by a coroner.
Medical examiners will play an important role in learning lessons from mistakes and improving patient safety. Importantly, they will seek and record the opinions of the relatives of the deceased and will document and pass on relevant concerns. Extensive pilot schemes have unequivocally demonstrated the many benefits of this approach.
Implementing these reforms was strongly supported by the Francis Report into poor care delivered at Mid-Staffordshire NHS Foundation Trust, where complaints from the bereaved relativies were ignored. The Report of the Morecambe Bay Investigation into maternal and infant deaths also called for the immediate introduction of medical examiners.
Medical examiners are due to be introduced in 2018. This report, as many before it, demonstrates just how important the role will be to help the NHS learn from its mistakes to safeguard future patients."
Notes for editors
In July 2016, the Public Administration and Constitutional Affairs Committee (PACAC) received a report from the Parliamentary and Health Service Ombudsman (PHSO), Learning from Mistakes: An investigation report by the Parliamentary and Health Service Ombudsman into how the NHS failed to properly investigate the death of a three-year old child. This was a second report from the PHSO into the death of Sam Morrish, a three year old child whose death from sepsis was found to have been avoidable. The report highlights systemic problems with clinical incident investigations in the NHS in England, where it found that a fear of blame inhibits open investigations, learning, and improvement.