Patient accidentally injected with disinfectant at DRI

Doncaster Royal Infirmary.
Doncaster Royal Infirmary.

The NHS ombudsman has been “defensive” and caused “pain” by its reluctance to admit mistakes when investigating patients’ complaints, an MPs’ report has found.

“Serious questions” have been raised about the Parliamentary and Health Service Ombudsman (PHSO) which has caused “considerable anguish” when it has failed to uncover the truth, it said.

The Public Administration Select Committee (PASC) has now called for a new independent body to investigate clinical failures before they reach the ombudsman to “transform the safety culture of the NHS”.

Current systems are “complicated, take far too long and are preoccupied with blame or avoiding financial liability”, the committee warned.

Bernard Jenkin, chairman of the PASC, said there had been an “urgent need” for a “simpler and more trusted” system for investigating clinical failures in the wake of the Stafford and Morecambe Bay hospitals scandals.

He said: “We embarked on this inquiry because we are aware of the considerable anguish and disquiet where Parliamentary and Health Service Ombudsman investigations fail to uncover the truth, and of pain inflicted by the Ombudsman when it has been defensive and reluctant to admit mistakes.

“Some of the PHSO’s shortcomings are systemic and can only be addressed through legislation, which is needed early in the next Parliament.

“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.”

There are more than 12,000 avoidable hospital deaths every year, the Department of Health estimates, while more than 10,000 serious incidents are reported to NHS England annually.

The “devastating impact” of clinical failures was highlighted by the case of a patient named only as “Gina” who was forced to have her leg amputated following an accidental injection of disinfectant at Doncaster Royal Infirmary in 2013, the PASC said.

“The quality of most investigations falls far short of what patients, their families and NHS staff are entitled to expect, and these failures compound the pain and distress caused to patients and their families by the original incident,” the committee said.

The PASC said patients and NHS staff deserved to have clinical incidents “investigated immediately” at a local level to establish facts and evidence, “without the need to find blame, and regardless of whether a complaint has been raised”.

There also needs to be a “clear, effective central system” for disseminating lessons learned from local incidents across the national NHS, it added.

A spokeswoman for the Parliamentary and Health Service Ombudsman said: “We will carefully study this report which raises important issues about the investigation of clinical incidents for the health system, as well as about our service.”

A Department of Health spokesman said: “We want to make the NHS the safest and most transparent healthcare system in the world. This includes improving investigations into serious incidents, learning from mistakes and restoring the trust of patients’ and their families.

“In our response to the investigation report into the unacceptable levels of care at Morecambe Bay we said we would do more to standardise investigations and that we would explore the possibility of an independent national expert service for trusts.

“We welcome this report and will respond in due course.”