Every complaint we receive is extremely valuable to us. Each one is logged on our database and helps us to identify patterns. This way we can build up a broad picture of safety issues over time.
But as a very small investigation unit, we can only conduct a small number of investigations each year (up to 30). We investigate concerns based on the way they impacts people and services, how widespread the concern might be and whether it is likely to produce safety recommendations that we can share at the widest level across the NHS.
How we decide to investigate
We look at how badly a safety issue has affected the people involved, both physically and emotionally. We usually discuss this with patients, families or carers during our preliminary investigations.
Through these interviews, we're able to build a full picture of how severe the incident is. It also helps us to identify the most serious issues as they’ve often had the most impact.
We also look at the impact on services - whether the safety issues have, for example, reduced the ability to deliver safe and reliable care. And we consider the public view and whether there has already been a broader loss of confidence in that area of healthcare.
We always look at the wider risk associated with the safety issues – how common or widespread a patient safety concern is and whether it spans different areas of healthcare and locations.
Some of the areas we consider include:
- do various care settings or organisations change the way they work to address a safety issue?
- have the issues taken a while to be recognised and are they recognised at the right level?
- has the issue existed over a long period of time and are concerns about that issue consistently raised?
- will it get worse or spread into different areas of the system if not addressed?
We aim to put learning at the heart of everything we do. We want to drive positive change to improve patient safety and part of that is being able to clearly show that our investigations will produce new information about safety issues.
We always look at whether we have a new perspective so that we can develop meaningful, influential and effective safety recommendations that benefit all of those working in or being for cared by the health service.
We’ll always evaluate at key points during investigations to ensure they are still meeting our criteria and reflecting our main objectives and principles.
What we cannot investigate
Sometimes we’re unable to investigate patient safety concerns. We know this might be disappointing and frustrating to families, patients and carers who have had a bad experience.
We want to be as open about these reasons as possible.
We cannot investigate issues that happened within NHS funded care in England before April 2017.
We cannot attribute blame or liability to individuals or organisations. Our sole focus is to find out what went wrong in an investigation so that it never happens again. We don’t blame any of the people involved. If you have concerns about individual staff members or particular trusts then we will not be able to help you.
We cannot conduct “second opinion” investigations for people who are unhappy with a previous one or who have had an unsatisfactory response to a complaint. It is also especially difficult for us to investigate an incident previously investigated by regulators, such as the General Medical Council or the police.
We have no legal powers We cannot force NHS trusts to cooperate with us. They need to collaborate with us voluntarily.