Ramsey, L., Sheard, L., Waring, J. et al. (5 more authors) (2025) Humanizing processes after harm part 1: patient safety incident investigations, litigation and the experiences of those affected. Frontiers in Health Services, 4. 1473256. ISSN 2813-0146
Abstract
Background: There is a growing international policy focus on involving those affected by healthcare safety incidents, in subsequent investigations. Nonetheless, there remains little UK-based evidence exploring how this relates to the experiences of those affected over time, including the factors influencing decisions to litigate.
Aims: We aimed to explore the experiences of patients, families, staff and legal representatives affected by safety incidents over time, and the factors influencing decisions to litigate.
Methods: Participants were purposively recruited via (i) communication from four NHS hospital Trusts or an independent national investigator in England, (ii) relevant charitable organizations, (iii) social media, and (iv) word of mouth to take part in a qualitative semi-structured interview study. Data were analyzed using an inductive reflexive thematic approach.
Findings: 42 people with personal or professional experience of safety incident investigations participated, comprising patients and families (n = 18), healthcare staff (n = 7), legal staff (n = 1), and investigators (n = 16). 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. Systemic fear of litigation not only failed to meet the needs of those affected, but also inadvertently led to some pursuing litigation. Staff had parallel experiences of exclusion, lacking support and feeling left with an incomplete narrative. Importantly, investigating was often perceived as a lonely, invisible and undervalued role involving skilled “work” with limited training, resources, and infrastructure. Ultimately, elusive “organizational agendas” were prioritized above the needs of all affected.
Conclusions: Incident investigations fail to acknowledge and address emotional distress experienced by all affected, resulting in compounded harm. To address this, we propose five key recommendations, to: (1) prioritize the needs of those affected by incidents, (2) overcome culturally engrained fears of litigation to re-humanize processes and reduce rates of unnecessary litigation, (3) recognize and value the emotionally laborious and skilled work of investigators (4) inform and support those affected, (5) proceed in ways that recognize and seek to reduce social inequities.
Metadata
Item Type: | Article |
---|---|
Authors/Creators: |
|
Copyright, Publisher and Additional Information: | © 2025 Ramsey, Sheard, Waring, McHugh, Simms-Ellis, Louch, Ludwin and O'Hara. This is an open-access article distributed under the terms of the Creative Commons Attribution License (CC BY). The use, distribution or reproduction in other forums is permitted, provided the original author(s) and the copyright owner(s) are credited and that the original publication in this journal is cited, in accordance with accepted academic practice. No use, distribution or reproduction is permitted which does not comply with these terms. |
Keywords: | patient safety, patient involvement, staff involvement, healthcare harm, safety investigations, healthcare litigation, qualitative research |
Dates: |
|
Institution: | The University of Leeds |
Academic Units: | The University of Leeds > Faculty of Medicine and Health (Leeds) > School of Healthcare (Leeds) |
Depositing User: | Symplectic Publications |
Date Deposited: | 08 Jan 2025 09:37 |
Last Modified: | 08 Jan 2025 09:37 |
Status: | Published |
Publisher: | Frontiers Media |
Identification Number: | 10.3389/frhs.2024.1473256 |
Open Archives Initiative ID (OAI ID): | oai:eprints.whiterose.ac.uk:221446 |