The Health Foundation welcomes Public Administration Select Committee recommendations on NHS clinical failure

The report Investigating clinical incidents in the NHS has been published today following an inquiry into NHS complaints and clinical failure by the Public Administration Select Committee.

Penny Pereira, Assistant Director of Strategy at the Health Foundation, said:

'We welcome the inquiry’s recommendations, including one for a truly independent, overarching approach to investigating and learning from the most serious clinical incidents that result in patients being harmed. According to our recently published safety briefing, Is the NHS getting safer?, the percentage of staff who say there is a blame culture in their organisation has risen during this parliament, so we are pleased that the committee recognises the importance of continuing to learn from previous incidents without creating a culture of blame, as described in the Berwick Review.'

Carl Macrae, a Health Foundation Improvement Science Fellow, and co-author with Professor Charles Vincent (Health Foundation Professorial Fellow) of the paper that helped prompt the PASC inquiry, said:

'There is an urgent need for a more systematic, independent and rigorous approach to investigating and learning from the most serious patient safety issues across the health care system. I welcome the recommendations laid out in this report, which will allow lessons to be shared nationally, build local capacity for investigation and improvement, and create a safe space for investigation and learning across the whole health care system.'

Notes to editors

Download Is the NHS getting safer? by John Illingworth, Policy Manager at the Health Foundation

Work that helped prompt the PASC inquiry, supported by the Health Foundation:

• Macrae C and Vincent C, ‘Learning from failure: the need for independent safety investigation in healthcare’ Journal of the Royal Society of Medicine; 2014, 107(11) 439-443 

The Health Foundation submitted written evidence to the Public Administration Select Committee.

Media contact

Thais Portilho, Senior Public Affairs Manager
T: 020 7257 8027
E: thais.portilho@health.org.uk