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NHS Investigations – Serious Incident and Independent Investigations Reports


Introduction to NHS Investigations

This is a Fathers summary of events after an NHS Investigation has concluded. It is a true story from a families perspective. It relates to my daughter’s original presentation to the Ipswich Hospital NHS Trust Accident and Emergency Department 2nd August 2015. My family had raised concerns about her care and treatment. Not that we were not appreciative of the efforts people had made during CPR, but we were extremely shocked when we were allowed into CCU to see her.

I and my family are not clinicians, but we did need to understand what had happened and we do have the right under the NHS duty of candour to be given some time to discuss what actually happened during treatment. We never pretended to understand what clinicians do but we felt some explanation about their basic treatment, care and investigation process would bring some comfort.

We had reported our concerns on a rolling basis face to face, by email and telephone over time. Some concerns had been followed up by the local CCG. All the correspondence had been retained. I raised concerns and reported the Trusts failure to be open and honest and transparent. I was never informed by the local hospital that my daughter’s incident was a serious incident. The default answer was “we will investigate everything that went wrong.”

The Ipswich Hospital NHS Trust

After a failed SIRI, independent investigation and review, we received a SIRI report (Version 3) from the Trust. This was July 19th, 2017, some two years after the incident that had led to a catastrophic outcome for our daughter.  The local Trust and CCG considered this heavily edited and amended report concluded their NHS investigations process. The Trust had made 877 deletions, amendments from the previous draft report we had seen. The Ipswich and East Suffolk Clinical Commissioning Group (IESCCG) concluded this report may reduce the impact to any reader of these learning points in relation to the number of opportunities to act. However, they supported the local hospital’s report and closed the case.

“Having been provided the opportunity to review Version 2 of the report which contained some draft elements that were amended in V3, it appears that the amendments do not materially change the meaning of the report. However, some of the amendments have led to key points e.g. opportunities to seek advice and escalate concerns, being highlighted in the V3 report on fewer occasions than in the earlier version. This may reduce the impact to any reader of these learning points in relation to the number of opportunities to act.”

Chris Hooper
Interim Chief Nursing Officer

The Ipswich Hospital NHS Trust

In 2017, the CEO of the Trust Nick Hulme who had never responded to any correspondence in two years, despite copying him into many emails, now responded. He firmly closed the door to any future engagement with the local CCG, referring us to the PHSO. A few days later after contacting the CCG, they also followed the same instruction in writing, closing the door to any further engagement and referring the family to the PHSO.

Hulme-Apology-2017

NHS Investigations - Nick Hulme Ipswich Hospital NHS Trust

References and Guidelines for NHS investigations:

Serious Clinical Incident Group (SCIG) reference here

Serious Incident Requiring Investigation (SIRI) reference here

The General Medical Council (GMC) here

The Nursing and Midwifery Council (NMC) here

The Ipswich Hospital NHS Trust Complaints Handling Policy V5 Document here

Original Serious Incident requiring investigation report here (will be updated soon)

Investigations report into SIRI conducted by (IHT) (will be updated soon)

Independent Investigation Medical report conducted by (IHT) (here)

The Ipswich Hospital NHS Trust SIRI report recommendations here

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