When something goes wrong, the NHS has a responsibility to learn from it and to prevent it from happening again. When this results in serious harm to anyone, the weight of responsibility to learn and improve is even greater. Within the NHS we call these Serious Incidents and each NHS organisation has a policy through which these are identified, investigated, lessons learnt and improvement made to reduce the risk of recurrence.
All local NHS organisations’ approach to managing Serious Incidents stems from the national Serious Incident Framework. This is ‘owned’ by NHS England and was originally established in March 2013 for a relatively new organisation to lead the process throughout the NHS in England. It is currently under review and it is recognised that a much greater focus is needed on the learning from serious incidents whilst also ensuring a consistent and proportionate approach to investigation and incident management. Key to this is to put the patient and/or family at the centre of the process and to ensure that they are involved as much or as little as they want to be in this.
This week I attended a meeting as part of the NHS England Patient Safety Team’s consultation with staff from commissioners and providers in our local area. This was to talk to us about the current review of the framework and get our feedback on the latest draft. It was a great opportunity for us locally to influence how this evolves nationally and for the national team to get a feel for how things work at the front-line and to ensure that the framework reflects practical realities. This was only one of a series of meetings that the national team were running to engage with staff who have good practical experience of managing serious incidents and the background evidence of what works and what doesn’t to improve outcomes for people.
Inevitably, the discussion about the proposed new framework got into some of the detail of what will change and what won’t, such as: Will or won’t commissioners require providers to submit update reports 72 hours after the incident is discovered? Will all Grade 3 pressure ulcers continue to be deemed as serious incidents? What will change on the list of Never Events, and will this form part of the framework or be kept separate? How will disputes be resolved where a commissioner and a provider don’t agree as to whether an incident is ‘Serious’ or not…
Personally, the most valuable part of the conversation was when we discussed the overarching values and principles that should form part of the Framework. If we try to legislate for every single minute detail or circumstance that may occur; firstly we’ll never see the revised Framework, as it will take a decade to write and secondly, it will be the size of several volumes of the Yellow Pages! However, if those principles and values that over-arch and underpin the framework are clearly stated and agreed by those operating within it, any issues not specifically detailed in an appendix or flow-chart should be easily resolvable.
Ultimately, I believe that the following two things are most important in this:
1. Ensuring that the person involved in the incident and/or family is at the forefront of the minds of anyone involved in investigating it to ensure they are treated with dignity and compassion throughout. The needs of the individual should come above protecting the reputation of any organisation; and
2. A rigorous focus on learning at all levels must be applied, to include those directly involved, local services, units, organisations, wider local stakeholders and feeding into a system to genuinely contribute to learning across the NHS to reduce risk in the future.
SInce writing this post, I have become aware of a consultation by the Care Quality Commission on draft guidance on implementing the new regulations on 'Fundamental Standards'. This includes a Fit & Proper Person Test for people sitting on providers' Boards. The following is a section from the guidance that describes the requirements for a fit and proper person:
"In addition to the usual requirements of good character, health, qualifications, skills and experience, the regulation goes further by barring individuals who are prevented from holding the office (for example, under a directors' disqualification order) and significantly, excluding from office people who:
"have been responsible for, been privy to, contributed to or facilitated any serious misconduct or mismanagement (whether unlawful or not) in the course of carrying on a regulated activity, or discharging any functions relating to any office or employment with a service provider".
This is a significant restriction. It will enable CQC to decide that a person is not fit to be a director on the basis of any previous misconduct or incompetence in a previous role for a service provider. This would be the case even if the individual was working in a more junior capacity at that time, or working outside England."