Investigations into NHS complaints are often incompetent and fail to learn from mistakes, the ombudsman has said.
A recently published report has demanded an overhaul of the way in which NHS complaints are handled.
Currently, mistakes are investigated by the staff or organisation against whom the complaint is against.
NHS ombudsman Dame Julie Mellor has said this must change, as investigations are often focused on avoiding blame rather than accepting responsibility.
The report suggests that because there is rarely an admission of fault, GPs and hospitals are failing to learn from mistakes, and are not uncovering what went wrong and why.
A national programme to train NHS investigators was recommended as an alternative.
The report was prompted by the death of three-year-old Sam Morrish, who died of sepsis in 2010.
He was repeatedly sent home by his GP, hospital staff and out-of-hours services in the days leading up to his death.
When he was finally admitted to hospital, there was a long delay before antibiotics were administered.
Afterwards his parents, Scott and Sue Morrish, were told nothing more could have been done.
They refused to believe this and referred their complaint to the ombudsman, which found Sam’s life could have been saved.
Mr and Mrs Morrish pushed the matter further, asking why the original investigation did not admit there had been failings – something which could prevent other children from dying in the future.
Talking of Sam’s case, Dame Julie said: “like so many others, [it] shows that organisations were not competent in the way they investigated this serious complaint and that this incompetence went unchallenged.”
Mr Morrish said: “I hope this report leads to rapid change in the culture of the NHS so that mistakes can be recognised, investigated and learnt from. Anything short of that isn’t safe for patients and isn’t fair to NHS staff.”
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