Care Quality Commission reviews how NHS acute trusts are learning from serious incidents

Published: 5 July 2016 Page last updated: 12 May 2022

CQC has published the findings of its review of how acute NHS trusts report on investigations into serious incidents, and the extent to which they identify learning that can be used to improve practice when things go wrong.

The review – Learning from serious incidents in NHS acute hospitals: A review of the quality of investigation reports – was based on a sample of 74 investigation reports from 24 NHS acute hospital trusts. The sample reports related to incidents that had occurred between April 2014 and October 2014.

The findings of the review have been published in a briefing paper which highlights a variation in the quality of investigations and echo the main issues already raised by the Public Administration Select Committee, Parliamentary and Health Service Ombudsman, and others.

The briefing also provides a number of good practice examples and identifies the following five opportunities for improvement for NHS acute trusts:

  1. Prioritising serious incidents that require full investigation and developing alternative methods for managing and learning from other types of incident.
  2. Routinely involving patients and families in investigations.
  3. Engaging and supporting the staff involved in the incident and investigation process.
  4. Using skilled analysis to move the focus of investigation from the acts or omissions of staff, to identifying the underlying causes of the incident.
  5. Using human factors principles to develop solutions that reduce the risk of the same incidents happening again.

Prof Sir Mike Richards, Chief Inspector of Hospitals at the Care Quality Commission, said:

"A service that is safe and well-led will see every serious incident as an opportunity to improve, will support staff to raise concerns within a culture of learning not blaming, and will recognise the need to involve patients and their families when reviewing why and how incidents have occurred.

"Unfortunately this is not happening everywhere. The needs of patients and their families are not always given priority and the analysis of events sometimes fails to identify the underlying causes that led to the incident in the first place.

"Investigating serious incidents is a powerful way the NHS can learn from mistakes, reduce or eliminate the risk of harm or death, and improve patient care.

"We will incorporate our learning from this review into the development of our inspection methodologies. We will also be working closely with the Healthcare Safety Investigation Branch to support local organisations and encourage improvements in their processes for investigating serious incidents, so that we can be confident patients receive the safe, high-quality and compassionate care they deserve."

Investigating serious incidents is a powerful way the NHS can learn from mistakes, reduce or eliminate the risk of harm or death, and improve patient care.

Professor Sir Mike Richards, Chief Inspector of Hospitals