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 into a serious medical incident. 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 Critical Care to see her.
We are not clinicians
I and my family are not clinicians, but we did need to understand what had happened to our daughter. We understood we had the right under the NHS’s ‘Duty of candour’ to be given some time to discuss what actually happened during treatment. It is the duty of all NHS healthcare providers to provide safe and effective care to service users. They must also demonstrate a transparent, open and honest account of events when things go wrong.
Read our experience NHS Investigation Process For Families
We never pretended to understand what clinicians do but we felt some explanation about their basic treatment pathway, care would bring some comfort. After we were told there would be an NHS Investigation, we reported our concerns on a rolling basis face to face, by email and telephone over a period of time. Some concerns had been followed up after we contacted the local CCG.
All correspondence to the Trust and CCG had been retained. I raised further concerns and reported the Trusts failure to be transparent, open and honest. At no time after my daughter’s catastrophic outcome was I informed my daughter’s incident was a serious incident. The default answer was “we will investigate everything that went wrong.” After two days I went into the Accident and Emergency department at Ipswich Hospital and asked to speak to someone.
The Ipswich Hospital NHS Trust SIRI
After the first 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 my daughter’s 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.”
Interim Chief Nursing Officer
The Ipswich Hospital NHS Trust is now known as ESNEFT East Suffolk and North Essex Foundation 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.
The GMC fitness to practise process for families
After the closure of my daughter’s case at Ipswich Hospital and the local commissioning group in 2017, I decided to contact the general medical council (GMC). These UK regulators will investigate Doctors fitness to practise if your concerns meet their threshold for investigation. I will provide the link below to the blog post which details this process. Initially, your concerns must pass the preliminary enquiry stage, this was changed in 2017, otherwise, your case will be closed with no further investigation.
Independent Investigations and Expert opinion
GMC investigations are carried out by case examiners who have no relationship to the healthcare provider, unlike NHS Investigations which are predominantly internal investigations conducted by their own staff. In my daughter’s case, this even included a chairperson who provided treatment to her in critical care and one could say he formed a potentially bias opinion of her outcome based on prior clinical knowledge. He was neither experienced in serious incidents of this nature and did in fact form the view “she was in the right place and received the appropriate treatment” Dr Robert Lewis, Consultant Anaesthetist, Ipswich Hospital SIRI 2015.
This is the link to my recent blog post The GMC fitness to practise process for families
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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