Formas de compra

A senior clinician had serious concerns about a planned merger of departments and raised them with the CEO. The consultant was then contacted by her HR Director, who assured her that her concern would be looked into and that it was being recorded and treated as a protected disclosure. An independent investigation was set up, in consultation with the consultant to ensure she was satisfied with the choice of investigator, and she was kept in the picture at all times. The investigation did not uphold the concern, but the clinician accepted the finding and the rigour of the process.

She later overheard colleagues discussing that raising concerns was a waste of time. She disagreed, and told how she had spoken up, her concerns had been thoroughly investigated, and she had felt well supported and protected throughout. She said she would encourage them to do the same.

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6.4.8 The written contributions and meetings identified examples of practices that had led to positive experiences for those who had raised concerns. These included:

• collaboration between medical and nursing directors

• close working relationships between clinicians and managerial staff

• advice from external experts

• protection of identity.

6.4.9 Focusing on issues when they are ‘small’ and/or isolated can prevent them escalating or happening elsewhere in the organisation. Poor practice

6.4.10 However, the written contributions and meetings also identified many examples of poor practices in terms of the investigation process. These included:

• concerns not acknowledged

• failure to investigate and act

• ‘biased’ investigations

• lack of transparency and openness

• poor communication.

6.4.11 There were also concerns about unsubstantiated and false allegations. Timescale of investigation

6.4.12 The quicker an issue can be investigated the better. There was overarching support at the seminars for logging receipt of a concern and a timescale for acknowledging its receipt. However, there was little support for a nationally specified timescale for completing investigations. It was accepted that different issues would need different approaches and the key was to inform the person who had raised the concern about the expected timescale for investigation and of any changes to that.

Investigation

6.4.13 Seminar participants agreed that is was key to have:

• arrangements for fair and proportionate investigations only independent of the organisation where appropriate

• a pool of people who are trained to undertake the investigation of concerns.

6.4.14 This was reinforced at meetings with representatives from other sectors who confirmed that:

• trained investigators can make a real difference

• investigations should be undertaken separately from the local team

• it is important that investigations are seen to be done properly and that appropriate resourcing is provided.

6.4.15 Of course there will be occasions where a concern cannot be dealt with quickly and simply. This reinforces a point frequently expressed to the Review that a one size fits all model for handling concerns is not possible.

“ There are also the cases which become more complex than initially envisaged, with ongoing investigations that can be unsettling to everyone involved.”

6.4.16 However we did hear a range of ideas for what a good investigation process would look like, which, taken together form the principle ingredients of good practice. These are incorporated into the good practice summary at the end of this section. Independence of investigation

(including external investigation)

6.4.17 The need for, and value of, independent investigation of concerns was highlighted by many contributors. A solicitor with experience in handling whistleblowing cases across different sectors noted that one reason whistleblowing goes wrong in the

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NHS is a lack of independent investigation. Other contributors also expressed scepticism and distrust of investigation of their concerns.

“ Where [the issue is one of] processes rather than individual competence, […] the familiar problem of those in charge of the systems investigating themselves arises.”

“ Reviews were often said to be dealing with […] concerns, but lacked integrity and did not intend to resolve the issues so much as push them under the carpet. It made little difference whether they were carried out externally or internally; in both scenarios, it was possible to engineer findings to evidence a premeditated outcome.”

6.4.18 The value of having an independent element to the investigation is that it provides objectivity so that the conclusions are more likely to be accepted by all sides, and bring closure to the issue. There were differing views as to whether investigation of concerns should be independent of the team only or independent of the organisation. Although some thought an investigation should always be external to the organisation, the majority advised that concerns should be investigated by people who are independent of the issue being looked into and that potential conflicts of interest should be identified and avoided. This did not mean necessarily that concerns had to be investigated by people external to the organisation. Staff from other departments or sites might be an option. It was noted that this might be more challenging in highly specialised areas or small organisations, although reciprocal arrangements with neighbouring services might be possible.

6.4.19 I do not consider it would be fair to insist that someone raising a concern should have an automatic right to request an external independent investigation. Nevertheless there will be many circumstances where external independence would be desirable. The degree of independence needs to be proportionate to the gravity or complexity of the issues and the seniority of those involved

where it will be harder to find someone within the organisation who does not know them.

“ An external team can provide a catalyst for dialogue where communications have broken down, often pointing out areas for change on both ‘sides’ and providing a calm and credible explanation for behaviours and attitudes which may be a result of pressures in their own jobs.”

6.4.20 Wherever investigators come from two things are essential. The first is that they have appropriate training and know how to conduct, and report on, an investigation quickly and with impartiality. The second is that they have dedicated time to do it, and are not being asked to ‘squeeze’ it into their other duties. It may indeed be helpful to establish a panel of accredited investigators or experts to whom an organisation could turn, similar to air accident investigators. This might be something that could be led by an Independent National Officer (see 7.6) or the National Reporting and Learning System (NRLS). It would have the additional benefit that this panel could be used as a means to identify system wide issues and share learning.

Feedback

6.4.21 One of the strongest messages from both individuals and organisations was that feedback after raising a concern is vital for both individuals and other staff in organisations. This should include evidence of action being taken as a result of a concern or reasons if not. Without feedback staff are unlikely to see the point of raising concerns in the future, there may be suspicion about action or inaction, and there will be lost opportunities for wider learning.

“ If a member of staff is bothered enough to identify a serious problem and identify a sensible solution then there should be an ethical obligation for somebody appropriate to sit down with them and talk it through, even if it is unfeasible for reasons they hadn’t understood.”

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6.4.22 The results of our staff surveys indicate that there is still more to do on this:

• 26.6% of trust staff who answered this question (493 of 1855) noted that they were not told the outcome of the investigation into their concern

• 20.6% of primary care staff (77 of 374) noted that they had not been told the outcome of the investigation into their concern.

6.4.23 The qualitative information we received confirmed that the absence of feedback:

• could deter people from raising concerns in the future

• could trigger unnecessary escalation of the concern either internally or externally

• made it more likely that the person raising the concern would feel frustrated or aggrieved.

6.4.24 Many contributors were aggrieved at the way their concerns were treated. Some of these people would have been more likely to accept a decision, even if they did not agree with it, if they had been involved in the process and given feedback from the outset.

“ The thing that makes me most angry was that no-one had a duty to explain why the decision was taken that this service improvement, which appeared to be feasible, affordable and life­ saving, was not going to happen. I think if that had happened I would probably have found it easier to accept in the long run.”

6.4.25 Employing organisations did highlight the potential difficulty in providing full feedback while preserving the confidentiality of those involved. However, the interview-based research indicated that the importance of feedback is still not being thought about enough.

“ They get an acknowledgement, and they know it’s being taken forward. What I think we don’t do so well, and what comes back to us, is we don’t give detailed feedback as well as we might, and I think that’s a gap for us if I’m honest.”

6.4.26 It may not always be possible to give full details of the conclusion. For example, the cause for a safety concern might be found to be inconsistent performance by a doctor who is not well. Even though it would not be appropriate to give full details to the person who raised the concern, there will always be some information that can be shared. In some cases it may be that the staff member would consent to disclosure of at least some personal information, or be prepared to discuss the problem with the person who raised the concern. Appropriate feedback can be adjusted to take account of the circumstances.

6.4.27 There should be a presumption that the findings of an investigation will be shared with the person who raised the concern and any other staff involved. If it is not possible to share the full report for reasons of confidentiality, as much information as possible should be shared, redacting or editing only what is essential to respect the privacy of other individuals involved. Confidentiality should not be used as a reason to give no feedback at all.

6.4.28 This will be an important step in

maintaining the trust and confidence of all involved in the process that has been adopted. Even where direct sharing of information is inappropriate or impractical, for example where the information has come from an anonymous source, there are still ways to feedback to staff about concerns. Examples of what is happening already include:

• fact or fiction noticeboards to deal with concerns and rumours

• feedback on whiteboards, noticeboards and bulletins, for example ‘you said, we did’

• weekly e-communications listing every concern raised by staff that week and the organisation’s response and/or proposed action

• feedback from consultant and a clinical governance trainee review of specialty specific incident forms to the rest of the department. Conclusion

6.4.29 Three main things came out of the evidence in relation to the investigation of concerns:

• the importance of establishing the facts

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necessary, independently of everyone involved with the issue, in a way that has the confidence of all parties

• feeding back to the individual and sharing learning more widely.

6.4.30 A decision should be taken at a level of seniority appropriate to the gravity of the issues raised about the appropriate response, including, where relevant, a programme of proposed action to

address the safety issue identified and any learning from it that might be shared more widely. This should also be shared with the person who raised the concern. Wider learning should be shared across the organisation (see 7.4 on transparency).

6.4.31 Investigations should be carried out in accordance with the following good practice which should be incorporated into the organisation’s policy and procedures described in Principle 2.

Good practice – Handling concerns (the investigation process)