The Department of Health will announce in the next month major
changes to the methods used nationally for health and social care
inquiries. The new system will also cover homicides by mentally
disordered patients, replacing the series of ad hoc inquiries
introduced after the Clunis Inquiry in 1994.
The NHS National Patient Safety Agency (NPSA) is to operate the
system but the health secretary will still have the power to
commission other forms of major inquiry when, and if, the
circumstances or public interest demand it.
Investigations will use root cause analysis (RCA), which provides a
set of methods to aid investigation. The methods were developed in
areas such as aviation that depend on high levels of safety. RCA
aims to identify the causes of failure in operational systems and
the actions that are needed to avoid this being repeated.
The NHS has been using RCA since last December to examine its care
and treatment of patients and to scrutinise wider issues such as
staff selection, training and updating, support and supervision,
briefing and debriefing, procedural guidance, management
accountability and organisational effectiveness.
In every case, the RCA approach starts from an assumption that most
human errors are induced by system failures and therefore pointing
the finger of blame at individual staff is unproductive.
This is consistent with the values expressed by the NHS when it
introduced NPSA in 2001.1 It described the principles
underpinning the new agency’s reporting and learning roles in terms
of fairness, openness and respect for anonymity, as well as for
partnership working, involvement of patients and public,
accessibility and learning from experience.
This full commitment to trust and avoidance of blame has been
acknowledged as essential to the effective use of RCA elsewhere;
for example, in the investigation of aviation disasters or rail
crashes. Such investigations have generally involved human error
set within complex operational and organisational systems. They
have also involved issues of equipment use and procedures, as well
as training, monitoring and support of the workers who were
directly involved with customers.
Adopting the principle of avoiding blame will surely resonate for
anyone who has participated in one of the many inquiries relating
to mental health clients and children in care. The benefits of the
new approach to investigating health and related social care
systems are welcomed as much by those of us who have presided over
inquiries as by the professionals called to give evidence.
Over the years, inquiries have evolved procedures, often guided by
case law, which have helped panel members to follow a step-by-step
approach to the examination of evidence. They have, however, lacked
a nationally recommended framework, either to aid their
investigations or to facilitate the overall collation of findings.
This has been a notable shortcoming in more than 100 mental health
homicide inquiries since they started in 1994.
Since Maria Colwell in 1974, the context of each inquiry has
differed greatly, mainly due to changes that have been made to care
and protection systems. The inquiries have often led to reforms in
legislation and guidance and have contributed to the restructuring
However, the inquiry reports describe few differences in the
quality of evidence-based practice by workers and their managers.
In particular, the inadequate reporting of workers’ direct contacts
with each child, or sometimes their complete absence, had at key
stages fatally diminished the impact of first-hand evidence on
decision-making. The changes to procedures and systems had not
improved the performance of those who carried out statutory
responsibilities in face-to-face contact with the children and
carers. In effect, the changes to systems had failed to reduce
The evidence that attracted most attention at Lord Laming’s public
hearings into the death of Victoria Climbi’ described systemic
failures with casework practice and supervision as well as serious
omissions, inconsistencies and errors in the case recording or
reporting and in communications within and between agencies. As a
result, information on Victoria observed at first hand by social
services, NHS, police and others was not acted on.
Contacts between staff and their immediate supervisors, several of
whom were unfamiliar with local conditions and procedures, were
said to be so patchy that staff knowledge and experience were often
not available when decisions needed to be made or reviewed.
Meanwhile, senior managers believed that the policy and procedural
systems they had set up were so well established that actual
practice should have been satisfactory, and that the absence of
“failsafe” reports to the contrary justified their optimistic
assumptions. In fact the back-up mechanisms at all levels did not
operate because relevant safeguards were not activated.
These themes echo the findings of the many child care inquiries
tracing back to Maria Colwell in 1974.
Mental health homicide inquiries have told a similar story, and
their findings have also contributed to national policy statements,
guidance on practice standards and service frameworks. The law
itself is to be reformed, partly in the light of accrued
Despite this, the most recent inquiry reports continue to list
serious deficiencies in evidence-based practice by staff who were
in direct contact with patients and carers. Reports often describe
poor adherence to national practice guidance or in implementing
recommended systems of treatment and care on the part of
clinicians, their supervisors and senior managers.
For RCA to have a real impact on such repeated failures, the NPSA
will need to include some essential questions as it gathers
evidence for its investigations. For example:
- Do current operational and organisational systems sufficiently
support standards of professional competence for staff who carry
out statutory responsibilities as first-hand witnesses?
- Are the roles of those staff given primary status, or have
systems become the end rather than the means to support good
- To what extent have organisational systems of care in the
community become institutionalised?
- In what ways are policies relating to equality and social and
cultural diversity allowing the fulfilment of operational procedure
for the protection of children or mentally ill adults?
RCA has done much to enhance safety in the airline business. Its
use in investigating system failures in health and related social
services is expected to make a similar impact.
Richard Lingham is a chairperson and adviser on Department
of Health inquiries. A former social services director for Cornwall
and the Isles of Scilly, he was a Mental Health Act commissioner
and is a qualified psychiatric social worker.
1 Department of Health, An Organisation With A
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