Safeguarding

34 CHAPTER 4 CLINICAL GOVERNANCE
Possible escalation to the Healthcare Commission or other bodies
Shipman Inquiry recommendation 13: The draft Complaints Regulations, when implemented,
should include a power enabling PCTs to refer a complaint to the Health Commission for
investigation at any point during the first stage of the complaints procedures. Cases raising
difficult or complex issues or involving issues relating to both primary and secondary care might
be referred to the Healthcare Commission for investigation at the time of the second triage, or
later if the investigation by the inter-PCT investigation team raises more complex issues than had
initially been apparent. Referral to the Healthcare Commission should also take place in cases
where the inter-PCT investigation team has found that it cannot reach a conclusion because
there remain unresolved disputes of fact. The purpose of the referral would be for the Healthcare
Commission to carry out any further necessary investigation, and, if appropriate, to set up a panel
to hear oral evidence about the facts in dispute and to decide where the truth lay.
Kerr/Haslam Inquiry p32: Chief Executives acting on the advice of their complaints managers
should be given the authority to refer a complaint to the Healthcare Commission for further
consideration.
4.18 We agree in principle that there could be advantage in providing some resource to help
healthcare organisations with the most complex investigations, especially those involving patient
safety incidents (see para 2.16) or health professionals working across more than one organisation.
A number of health communities have already developed specialist investigative capacity of this
kind (see para 4.34 below).
4.19 The Government is not convinced that it would be appropriate to give an automatic right for
frontline healthcare organisations to refer complex complaints to the Healthcare Commission; this
would undermine the drive to improve the skills and capacity of healthcare organisations to meet
their own requirements, and would distract the Healthcare Commission from its primary
responsibility to ensure and assess the safety and quality of organisations as a whole. However,
there may be occasions in which the investigation of performance issues relating apparently to a
single individual may indicate some deeper structural problems in the organisation. In these
circumstances, it would be entirely appropriate for NHS bodies to alert the Healthcare Commission,
and in turn for the Commission to investigate those incidents which meet its investigation criteria.