News – CQC Learning from serious incidents in NHS acute hospitals

“One of the most common issues we find is the way that organisations investigate, communicate and learn when things go wrong.” Says the CQC in their review into the quality of investigation reports.

This briefing document discusses the need for a change in the way that serious incidents are investigated and managed in the NHS.

It is based on the findings of a review of a sample of serious incident investigation reports from 24 acute hospital trusts. This sample represented 15% of the total 159 acute hospital trusts in England at the time of review.

The briefing provides a summary of their findings, linked to five opportunities for improvement and calls for all organisations to work together across the system to align expectations and create the right environment for open reporting, learning and improvement.

Five opportunities for learning:

  1. Serious incidents that require full investigation should be prioritised and alternative methods for managing and learning from other types of incident should be developed.
  2. Patients and families should be routinely involved in investigations.
  3. Staff involved in the incident and investigation process should be engaged and supported.
  4. Using skilled analysis to move the focus of investigation from the acts or omissions of staff, to identifying the underlying causes of the incident.
  5. Using human factors principles to develop solutions that reduce the risk of the same incidents happening again.

On learning opportunity 1, the CQC concluded that “Some of the incidents we reviewed would have benefited from alternative approaches, using less complex but more efficient ways to address the needs of the patient(s) and to identify any mitigating actions that could prevent the incidents happening again”.

Learning opportunity  2, the CQC quotes the Serious Incident Framework, saying, “the needs of those affected should be a primary concern for those involved in the response to and the investigations of serious incidents.”. They CQC went on to say that the guidance recommends that patients and families should provide the support, information and answers that they require. This report, while not being able to conclude that patients and families were not informed, it did not demonstrate expected guidance was being met. (Only 12% of the reports showed cleared evidence of the patients and families being involved).

Learning opportunity 3, the CQC stated that when serious incidents happen, it can have a profound effect on the staff that should be supported. It stated that skillful management of interviewing staff in a non-threatening and honest environment is required.

Learning opportunity 4 highlighted that only 8% of the CQC reports showed evidence of a clearly structured methodology  identifying:

  • the key issues to be explored and analysed
  • the contributory factors and underlying systems
  • the key causal factors that led to the incident

Learning opportunity 5 focused on organisations not always following guidance and so missing failures to stop re-occurrences.


This CQC report concluded that “Provider organisations have a primary responsibility for making sure their staff have the skills they need to carry out quality investigations. They should have external expertise when needed and opportunities to contribute to wider improvement initiatives when incidents may not warrant a formal investigation…..Trust boards must ask themselves if their investigations are making a difference and leading to improvement”.

The CQC called for all to come together, including the new Healthcare Safety Investigation Branch to provide, amongst other objectives:

“support to hospitals to develop the capacity that is required to encourage and embed good investigative practice into their wider approach to learning and improvement, and to make sure that patients and their families are informed and involved, in line with the Duty of Candour”

Original source:

Relevant events to support the CQC requirements outlined in this report:

Using Empathy to Help Resolve Complaints (and aid investigations)

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Blog – 3 Things you need to know about empathy and complaints

Complaint-rubber-stampSo you have another complex, difficult complaint to deal with? Difficult emotions to handle? Investigation processes and procedures to manage? What possible use does empathy have to do with it………………….not much right ??


Empathy is a commonly used word, but it is an attribute that is all too often misunderstood, mismanaged or underused.

Working on such complex issues that arise in healthcare complaints, the capability to recognise and appreciate another person’s experience from their perspective is an incredibly powerful communication tool.

Psychiatrist Alberta Szalita From Columbia University states that ’empathy is consideration of another person’s feelings and readiness to respond’

So as complaints managers, doctors, nurses, head of departments and board members, how might empathy and emotional development, used effectively, help with complaints? Well ….


Someone bringing a complaint or concern to you, is wishing for you to understand things from their frame of reference – their experience.rG-57-Columns-2

Think about when you have been having conflict with a spouse, sibling, work colleague, department store. Raising a concern or bringing a complaint? Are you representing YOUR experience of the situation…or theirs? Are you wishing for them to at least try and understand YOUR experience, or just dismiss it in favour of their truth? What fuels your frustration. We will all have our own frame of reference.

Using empathy effectively helps open your eyes to the often strong feelings present.

Using empathy helps you to STOP and IMAGINE what someone is feeling. What frame of reference are they coming from? What therefore, might they need!


All too often the case with health and social care complaints, the issue can be very emotive and complex, often involving loss and grief. So….


Validate their experience 

expand-jung01Carl Yung the Swiss psychiatrist and psychotherapist who founded analytical psychology States that ‘Loneliness is not the absence of being surrounded by people, but being with people and not being able to express what is important to you’.

As a bereaved mum who has been through the NHS complaints system, I know first had the prolonged psychological harm that lack of empathy and the suppression of my experience, opposed to validating it and mine and my child’s life does.

Using empathy helps you to powerfully communicate with the person bringing the complaint. This demonstrates that what they say has real value and meaning. It shows that you not only you need to listen for an accurate and meaningful investigative process, but you care about listening.


 YOU are empowered to respond more personally, and protect your well-being too.


Many people feel that being more empathic, will lead to emotional burn out. But medical and neuroscience research shows that, it is not the developing and effectively using empathy with healthcare that leads to this. Moreso not having sufficient understanding and insight into our own emotions, reactions and management of these things. Skills in self awareness leads to personal growth and better overall well being. This in turn enables our empathy for others to be developed rather than depleted, which happens when we are stressed.

Using empathy and emotional development enables professionals to be better able to support and work in partnership with those raising a complaint.

Using empathy and emotional development supports professionals to observe, feel and understand, but not to take the emotion on themselves.

Want to find out more?

For staff training  on ‘Using Empathy to Help Resolve Complaints’ suitable for PALS, Complaints and patient experience teams and front line staff Email me on:   Call on:     07541 98 949

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Blog – The benefits of ‘Affective Empathy’

Empathy is a word used with common frequency. It is a word that many, especially those who consider themselves caring feel they possess. Not many people would feel shocked by the popular definition of ‘walking in someone else’s shoes. This is commonly termed as Cognitive empathy.  But empathy is not always understood or appreciated in practical terms of how you go from understanding to action that makes a difference.

I am talking about affective empathy here – the ability to respond appropriately to another’s needs. Many people can imagine what it might be like to experience something, but that is often where it stays. Skilled affective empathy takes it further and empowers you to use this insight that you have gained, to ask better questions and action more beneficial and personal outcomes.

Today on Twitter, I came across this news story from the Birmingham Mail that demonstrates this:

‘The parents of premature babies cared for by a neonatal nurse are helping her terminally-ill husband by raising funds for a desperately needed wet room in their home.

The families have come to the aide of lorry driver Pete Clohessey, 63, of Olton, who was diagnosed with Motor Neurone Disease last year.

Within months of the devastating news he has become reliant on a wheelchair and has to be continuously connected to a breathing aid.

Tracey, 49, a neonatal nurse practitioner at Heartlands Hospital, applied for a disabled facilities grant from Solihull Borough Council, but it was refused.

Now parents whose children were nursed by caring Tracey have joined forces to set up aGoFundMe page to raise the cash for the fixtures and fittings for the facility – with one dad carrying out the building work for free.

“We are both very grateful and humbled by the kindness and generosity shown by friends, family and strangers who have donated to the fund.” Said Tracey

Landlord Adrian Bates, who runs The Olton Tavern, heard about their plight and set up a GoFundMe page to raise £5,000 – with the target being exceeded earlier this month.

Tracey helped to care for Adrian’s daughter Rebecca who was born 17 weeks early weighing in a just 1lbs 6oz – less than a bag of sugar. And even Rebecca, now aged 15, has helped the couple by holding a cake sale – pocketing more than £400 for the fund.

Builder Anthony Coughlan, whose twins Hope and Martha were also nursed by Tracey when they were born early last year, has offered to do the work for free’. (Read more on the story here)

Paying back for kindness shown or affective empathy?

So what does this story demonstrate? Well without a doubt, the kindness, professionalism and care that Tracey has undoubtedly demonstrated in her career has been a significant factor in the choices of these people; we rarely forget who helped us in times of vulnerability. Tracey’s own affective empathy, used skillfully over the years, has enabled that process. But in concentrating on what has happened in response to Tracey’s husband’s illness and challenges,  all these people could have shown excellent cognitive empathy and left it there. Imagining and allowing themselves to experience another’s world, and that would be a great way of truly understanding. However what they did is they went further, they went into the realms of affective empathy whereby they allowed the knowledge that their cognitive empathy had provided them with….what must this really be like….to then respond with action that was fitting to not their needs, but the needs of Tracey and her husband.

The benefit?

Has it changed the illness? No, Motor Neuron Disease is, as Tracey put it, “an evil disease” Has it altered long term prognosis? No, there is no cure as of yet for this illness. But what using affective empathy has done is resulted in practical support and help that really will make a very significant difference to the day to day lives of two people who really needed it. It has shown them that they are not totally alone, and that something that was beyond Tracey and her husbands reach is now being achieved. Change has occurred through skillful use of empathy. Change that may be small, but when so personal, fails to be anything other than hugely significant.

I believe the benefits of affective empathy are great indeed!

To find out more about empathy, its use and how it can support best practice, go to our website

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For more on this story and the original source go to: