Introduction

With patient safety and learning a priority for all trusts, Hempsons’ risk and investigation specialists are able to help trusts to navigate complex investigations and produce reports which provide:

  • an accurate factual narrative
  • an analysis of risk
  • effective, achievable and measurable recommendations.

Our risk and investigation service is led by Richard Greensit and Liz Hackett, both of whom have considerable experience and expertise in healthcare litigation, statutory and non-statutory inquiries, inquests and advice across the acute, mental health and ambulance trust sectors, including across secure services and the prison estate.

Risk analysis reports

We have worked closely with some of our key clients to develop a process for harvesting and recording high quality data from each incident or dispute, such that we can subject the data to analysis, triangulation, and thematic review.

Partner, Richard Greensit leads on this work for Hempsons and it has resulted in him presenting key findings to the Getting it Right First Time (GiRFT) Assurance Board and other governance boards to explore, develop and embed new governance arrangements and clinical practices to prevent future liabilities and patient harm.

Case study

In-depth review of emergency department (“ED”) claims for a major teaching hospital.

The trust’s ED claims had gradually increased to become the largest by volume (reflecting the national picture). One of its strategic aims was to identify learning from past and current claims (as part of its Getting it Right First Time assurance board activities), targeting interventions and changes in process to improve patient experience and safety and reduce the number of claims arising from this significant area of clinical activity.

The trust has a drive towards creating a ‘just culture of safety’ and our expertise and analysis was called upon to support learning.

Analytics

We presented the trust with NHS Resolution’s scorecard data but then applied further detailed data based on our coding matrix, where we identify for each claim granular issues such as:

  • grade of personnel involved in the clinical incident
  • whether the incident occurred on a weekday, weekend or during a public holiday (when staffing might be an issue)
  • in- or out-of-hours
  • the clinical specialty
  • the specific injuries
  • whether there was a complaint and whether any concessions were made in the response
  • whether there was an SI or duty of candour investigation and whether either identified substandard care
  • whether we have obtained critical or supportive expert evidence
  • patient comorbidities
  • detailed reasons for the alleged negligence
  • whether any admissions of negligence had been made in the claim

How we added to the client’s capabilities

By introducing our own data, we can triangulate specific aspects of the dataset to enable thematic review and draw out insight to support risk management strategies. The trust had no mechanism for recording claims data which could then be triangulated in this way.

Strategic insights

We were able to identify quality insights from the claims profile, including common occurring injuries and the fact that most claims had, against expectations, arisen from in-hours activity, mainly during a weekday; none of which occurred during a public holiday.

As an example of the strategic insights we were able to deliver through this exercise, we identified that 72% of cases where there had been an admission of negligence had not been subject to SI investigation. This suggested that in a proportion of those cases:

  • the SI mechanism had either failed to identify a serious incident had occurred at the time, or
  • the criteria for initiating an SI investigation was perhaps not sensitive enough to catch cases where negligence had in fact occurred and the patient had come to some harm as a result

This was an important strategic insight for the trust, as it was mindful that the best learning and risk management would come as soon after the clinical incident as possible. It undertook further work around its SI process, specifically in the ED, to understand if any cases had ‘missed’ an SI investigation which ought to have been caught at the time, to recalibrate the system if so and to ensure that there was awareness of the SI process.

The purpose of a Hempsons diagnostic review of legal services is to evaluate work processes, procedures and cultures which support and inform how learning from incidents is captured and used to implement learning and improved patient safety outcomes.

By working with trust legal, patient safety, complaints and governance teams, our approach is holistic. We build a picture of the risk profile of the trust and to make recommendations at a strategic level to address and mitigate ongoing risk. We also make practical recommendations in terms of working processes and procedures aimed at improving working practices so to improve the identification of risk, the management of risk and learning from incidents.

Drawing on our considerable experience working with NHS trusts, the overarching objective is to produce a report which:

  • presents an accurate risk profile of your organisation
  • includes the evidence base for the risks identified
  • makes effective, achievable and measurable recommendations to mitigate risk and improve the ways in which your organisation captures learning

The aim is to work with you to improve the culture and effectiveness of learning from incidents as part of your aim to improve patient safety outcomes.

Independent and arms-length investigations, complaints and thematic reviews

Hempsons is experienced in supporting NHS trusts in undertaking investigations, complaints and thematic review, and in undertaking these independently of the trust or at “arms-length” to the trust.

These include:

  • complaint investigations
  • serious incident investigations
  • “fresh eyes” investigations where complaints responses and serious incident investigations have been rejected
  • thematic reviews in acute, mental health and offender healthcare environments
  • diagnostic legal reviews (legal services and risk)
  • supporting providers during:
    • mental health homicide reviews
    • homicide inquests, including extensive of work on the prevention of future deaths (reports, recommendations, actions plans and evidence)
    • criminal proceedings arising from homicides
    • regulatory proceedings arising from homicides
    • public inquiries
    • serious case reviews
    • safeguarding investigations
    • historic abuse investigations and inquiries
    • CQC investigations and prosecutions
    • HSE investigations and prosecutions

Our clinical risk and investigations services are led by an experienced healthcare partner who is also experienced in investigations, report writing and duty of candour. Where undertaking an independent or “arms-length” investigation, the appointed partner assumes the role of “Chair” and in appropriate cases will be supported by appropriately skilled colleagues and independent experts.

Whatever the nature of the investigation, there will be a focus on risk management and learning, through identifying:

  • what, if anything, went wrong
  • whether the incident / event / circumstances could have been prevented
  • what lessons can be learned to minimise the possibility of recurrence
  • learning recommendations; and
  • where appropriate, support Trusts in creating a measurable action plan

Clinical risk and
investigation training

Our lawyers undertaking clinical risk and investigation work regularly provide training for health and social care providers on a range of investigation and learning matters, including:

  • How to undertake an effective investigation
  • Report writing
  • Learning from deaths and adverse incidents

You can download this brochure as a PDF here.