NHS Investigation Reports can have different names; Serious Incident reports (SIRs), Root Cause Analysis reports (RCA) and Serious Untoward Investigation report (SUI).
The name of serious incident reports is changing and is likely to be called a Patient Safety Incident Investigation Report or (PSII) from 2022 onwards.
Regardless of the name of the report the process is similar, and the reports are produced by Hospital Trusts following an investigation into a serious incident.
The report can highlight any lapses in care or lapses in organisational systems such as computer errors that lead to a letter not being sent for example.
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In what circumstances can I expect an NHS Investigation Report?
There is no universally accepted definition of a serious incident however it can be described as an adverse or untoward event, where the consequences to patients are so significant that a detailed investigation is required.
Adverse events may include actions or lapses in care by healthcare providers resulting in an unexpected or avoidable death, unexpected or avoidable injury or serious harm. Investigation reports may also be written even where serious injury or death was narrowly avoided, sometimes referred to as a ‘Near Miss’.
If a serious incident is being investigated and a report is being produced, the Hospital will contact the patient or their family to invite them to be involved in the report and investigation.
This is to allow the family to suggest questions to be answered by the investigation and be involved in the report. They will also give a timeframe of when the report is likely to be completed.
It is important to note Covid-19 has had an impact on the timescales of completion of reports in some hospitals and if there is a backlog of reports this should be communicated to the family.
The usual timeframe for completion of reports is 60 working days but hospitals can take longer, and the family should be kept informed of the progress of the investigation. Sometimes any delay in the report is due to the complexity of the investigation.
Why are NHS Investigation Reports important?
Investigation Reports can be useful to patients and their families to explain what happened during their treatment, why, and whether there were any lapses in the care provided.
What can I expect in an NHS Investigation Report?
Once the Hospital has completed its investigations one of several conclusions may be reached.
They may conclude that the care provided was to a reasonable standard, it may highlight concerns with the care provided but nevertheless say the care was to an acceptable standard, or, the report may confirm the care provided was below an accepted standard and not in line with national guidelines or usual practice.
The aim of an NHS Investigation is not to apportion blame but to identify opportunities to learn and this may mean any Investigation Report does not specifically pick out individuals’ actions.
As of November 2014, there is now a statutory duty known as the duty of candour to be open and honest where lapses in care may have occurred during treatment which has or could have resulted in moderate or severe harm or even death.
During an investigation, it is likely the patient’s medical records will be reviewed alongside statements given by the treating staff. The hospital may also obtain reports from independent hospital consultants for an independent review of the care provided.
What if I do not agree with the NHS Investigation Report?
Hudgell Solicitors’ experience of Investigation Reports in medical negligence claims is that they are very informative and useful. We often help patients, or their families understand the findings.
We also know that the report may not always identify all of the lapses in care. In some cases where a report has been produced, our medical experts have gone on to identify further failings beyond those identified in the report.
Whilst some patients may be disappointed in the outcome of an NHS investigation and report, in our experience it is not unusual for a report to identify some lapses in care but not all.
I have received an NHS Investigation Report, what do I do next?
For some patients and their families, the Investigation can successfully lead to a medical negligence claim.
Some examples of cases where we have successfully represented patients when an NHS Investigation Report was produced are:
- A forceps injury during childbirth. The report identified an incorrect use of forceps, which most likely caused the birth injury.
- Where national guidelines were not followed, subsequently contributing to a stillbirth. The Investigation Report identified that had national guidelines been followed correctly, earlier intervention would have been arranged, and the infant’s sad death would have been avoided. Our independent expert went on to identify further failures, too.
- In a claim for a misdiagnosis of breast cancer which resulted in our client undergoing intensive surgery, radiotherapy and endocrine treatment, the report identified that the patient was exposed to the unnecessary side effects of treatment.
- Missed opportunities to diagnose the patient sooner were identified in a claim for delayed diagnosis of a groin hernia, which worsened the patient’s outcome.
- A patient suffered an unwitnessed fall whilst in hospital, which resulted in her sustaining a fractured hip. The report acknowledged a failure to carry out a fall risk assessment for the patient, which contributed to the fall.
Hudgell Solicitors are regularly contacted by patients or their families when they receive an Investigation Report. We can help patients and their families understand the report and its findings which can often be complex.
We would encourage anyone who has received an Investigation Report to contact us for a confidential consultation. Our expert medical negligence solicitors and lawyers are here for you. For a free consultation about your claim, get in touch today.
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