Humanizing processes after harm part 1: patient safety incident investigations, litigation and the experiences of those affected (3 January 2025)

Summary

This is the second main empirical paper from the NIHR (National Institute for Health and Care Research) funded Learn Together programme, led by Lauren Ramsey.

In this open access paper, authors explore the historical experiences of patient safety incident investigations within the English NHS. Importantly. They also explored and contrasted the experience from the perspectives of the three key groups of people affected: 

• patients and families 
• healthcare staff involved in an incident investigation
• incident investigators.

Content

Key findings include:

1) Patients and families started investigation processes with cautious hope, but over time, came to realize that they lacked power, knowledge, and support to navigate the system, made clear in awaited investigation reports.

2) Fear of litigation 'baked into' organisations, not only failed to meet the needs of those affected, but also paradoxically led to some families pursuing litigation.

3) Staff also experienced exclusion, lacked support and were often left with an incomplete narrative. 

4) Investigators reported investigating as a lonely, invisible and undervalued role, involving skilled “work” undertaken with limited training, resources, and infrastructure. 

5) Elusive “organizational agendas” seemed to be prioritized above the needs of everyone affected by incidents.