IMPROVEMENT THROUGH INVESTIGATION

The role of independent investigations, including parallel investigations

Ed Marsden, managing partner, Verita

National Healthcare Conference, Dublin 2015

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Recent investigations

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Aim

• What are the triggers?

• What are the benefits and risks

• What are the implications of parallel investigations – particularly focusing on an investigation being carried out by the police?

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What is an independent investigation?

• Evidence based review with details gathered from a wide range of sources

• External, impartial investigators

• Objective findings

• Lack of pressure from commissioners

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What are the triggers

• Severity of the outcome

• The law

• Degree of public interest

• Capacity and capability of an organisation to investigate itself

• Views of families or the public

• Likely scrutiny of outcome

• An organisation’s own policy

• It’s the right thing to do

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“The problem with free elections is that you can’t predict the outcome.”

What are the benefits and risks?

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Benefits

• A thorough and persuasive investigation that sheds light on a complex matter

• A full and truthful exposition of facts

• Victims, relatives and staff feel engaged and heard

• A powerful set of recommendations to support improvement and change

• An independent account that can be published

• Interested parties given a truthful and unbiased account

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• The investigation report doesn’t convince

• The investigation is procedurally unsound

• The outcome comes as a surprise

Risks

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Parallel investigations

• There is nothing in UK law that says investigating a crime comes before investigating a patient safety incident

• An MoU signed in 2006 gives healthcare providers the framework to ensure effective working of parallel investigations

• Two good reasons for running parallel investigations:• Patient safety• Relatives and families

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Summary

• Independent investigations are likely to gather even more traction in organisations working to the open disclosure policy.

• Every organisation should know when and how to commission an independent investigation.

• Seek advice before commissioning.

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Action

Are you clear about the circumstances that

would trigger such an investigation?

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Partnership with British Medical Journal (BMJ)

• Aimed at delivering patient safety programmes

• Based on our investigative experience and BMJ's quality improvement programme (QIP)

• Consultancy & online tools to guide interventions

• Currently working with a UK hospital on oxygen therapy & falls

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IMPROVEMENT THROUGH INVESTIGATION

The role of independent investigations, including parallel investigations

www.verita.net/Dublin-conference