Quality not Quantity.
When it comes to understanding the safety culture of an NHS trust it is not useful to only know the quantity of incident reports that are produced. I have recently read a piece in a newspaper, sent in by an NHS trust, stating that the CQC found them to be one of the top reporters of serious incidents in the UK, the trust felt this measure alone helped demonstrate their level of openness.
However, having experienced myself, and having spoken with many other parents whose children have died as a consequence of errors (which one might consider is about as ‘serious’ as it gets) I am afraid that at worst I know that a trust did not consider the circumstances met serious incident criteria and at best the trust raised ‘some’ of their errors (not all) in a report but played down their impact on the tragic outcome.
These reports frequently appear to myself and other members of Mothers Instinct to be an exercise in being seen to do the right thing, whilst actually identifying very little, , often failing even to accurately record the events that occurred, let alone then investigate these events properly and honestly identify all the errors and the impact of these for the patient.
Many parents read S.I reports and contact the trusts with recommendations for changes due to inaccuracy, or points for concern that have been missed. All too often these views are not acted upon causing great distress. One Chief Exec said “I appreciate there is a factual discrepancy between your description of events and what is recorded in the medical records and recalled by our staff. I cannot resolve that. Based on what is in the records, the care was reasonable” A perfect example of some NHS trusts attitude to parental involvement…
If the CQC is going to measure incident reporting, then it must contact the patients or families and ask them their view on the quality of the incident report, if they are satisfied, if they were involved, if they disagree with any of the information within etc. They must also seek to understand if there has been any inquest, civil litigation case or further independent review of events, and compare the findings of these with the serious incident report. If time, money, and further distress for the parents has resulted in far more information becoming available than was found in the original incident report, then questions must be asked about the competence and or motives of the original serious incident investigating teams.
Only by looking more closely in these ways can a trusts serious incident reporting be measured in a meaningful way.
22 November 2013