Publications/Guidance

Report of the Expert Advisory Group: Healthcare Safety Investigation Branch The report makes recommendations about establishing the Healthcare Safety Investigation Branch (HSIB) as well as how to improve investigation, and learning from investigation, across the health system. 

Maternity Choice and Personalisation Pioneers. In March 2016, CCGs were invited to express their interest in working with neighbouring CCGs to test ways of improving choice and personalisation for women accessing maternity services. This marked the first step of implementing some of the recommendations from the National Maternity Review: Better Births. A panel has now selected seven Maternity Choice and Personalisation Pioneers. 

Response to consultation: the National Guardian for the NHS - improvement through openness. This report presents a joint response from the CQC and the National Guardian's Office to a consultation on how the National Guardian's Office should be established and run. The joint response reflects the immediate priorities and functions of the National Guardian's Office which include: providing advice and support on the role of Freedom to Speak Up Guardians; setting up a support network; and establishing a programme of engagement events for board members and guardians. 

PHSO review: Quality of NHS complaints investigations. The Commons Public Administration and Constitutional Affairs Committee has published a follow-up report to a recent review by the Parliamentary and Health Service Ombudsman (PHSO) of NHS complaints investigations. it concludes that the new Healthcare Safety Investigation Branch (HSIB) will only succeed if the Government legislates to guarantee its independence and ensure that it provides a genuine 'safe space' for people to speak out about patient safety risks. 

Infant Mortality and Stillbirth in the UK. A POSTnote which reviews recent data on stillbirth and infant mortality rates in the UK and examines the factors contributing to increased risk. It then looks at the policy options that may help to improve health outcomes for infants and their families.

Strategic quality improvement: an action learning approach. The King’s Fund was commissioned by Oxleas NHS Foundation Trust to work with their quality board to facilitate an assessment of its existing approaches to quality improvement and to develop a strategy for future work. This case study details the approach and philosophy behind this work, which involved working with the trust’s five directorates to develop their ability to appraise their own approach to quality improvement with a view to improving performance, achieving better clinical outcomes and building further on the trust’s capacity as a learning organisation. 

Shaping the future: CQC's strategy for 2016 to 2021. This five-year strategy sets out CQC's vision and ambitions for a more targeted, responsive and collaborative approach to regulation so that more people receive high-quality care. It describes how CQC will combine learning from 22,000 comprehensive inspections with better use of intelligence from the public, providers and partners in order to focus inspections more tightly to where people may be at risk of poor care. The new strategy also aims to encourage services to innovate and collaborate to drive improvement. 

A report of investigations into unsafe discharge from hospital. This report highlights cases investigated by the Ombudsman service where people have been discharged from hospital before they are fit to leave or without making sure they can cope on their return home. Last year the Parliamentary and Health Service Ombudsman saw a 36 per cent increase in discharge related investigations. These found that people’s deaths or suffering could have been prevented if hospitals carried out the right checks before discharging people.

Mothers and Babies: Reducing risk through audits and confidential enquiries across the UK (MBRRACE-UK) Perinatal mortality surveillance report: UK perinatal deaths for births from January to December 2014. This report finds that there has been slight fall in the rates of stillbirths and neonatal deaths in the UK compared with rates in 2013 which continues the downward trend in rates from 2003 onwards. However, the overall trend masks variations in rates across the UK. The effect of gestational age on perinatal mortality rates was also explored in more detail in this report. This shows that around two thirds of stillbirths and neonatal deaths were of babies born preterm indicating that initiatives to reduce stillbirth and neonatal deaths must include a focus on reducing preterm birth as well as ensuring high quality care for women whose pregnancies reach full term.

Consultations

Consultation on changes to the NHS patient survey programme The survey programme is used to collect feedback on the experiences of people using a range of NHS healthcare services. The current programme includes surveys of adult inpatients, community mental health service users, people using maternity services, outpatients, children and young people’s inpatient services and accident and emergency patients. The CQC aim in consulting on changes is to ensure that the programme has maximum impact and value, and that it remains relevant and useful for those using the survey results across the health and social care system. The consultation will run to 21 July 2016

Department of Health consultation on clinical negligence expected this summer. The Law Society advises that the DH intends to launch a consultation on the introduction of a fixed-costs regime for some clinical negligence claims in summer 2016, either in May or after the EU referendum. Responding to the DH pre-consultation in 2015, the Society argued that there should be a review of Legal Aid, Sentencing and Punishment of Offenders Act 2012 before any fixed-fee scheme was implemented.

News

Air Accident Investigation chief set for top NHS role at HSIB The existing head of the UK’s Air Accident Investigation Branch is set to become the chief investigator of the new NHS patient safety body. Keith Conradi, formerly a professional pilot, has been selected by health secretary Jeremy Hunt as his preferred candidate to lead the new Healthcare Safety Investigation Branch.

Fixed costs - Government admits defeat in bid to introduce fixed costs in clinical negligence on 1 October. The government has admitted that it will not be able to introduce fixed recoverable costs for clinical negligence cases on 1 October as planned.

Royal Berkshire NHS Foundation Trust has been fined £200,000 for safety failings in its management of the use and maintenance of trolleys. A Health and Safety Executive (HSE) investigation found there was a lack of maintenance of Anetic Aid QA3 trolleys at the hospital and a lack of training in an essential aspect of their use. 

BUPA Care Homes (CFC Homes) Ltd has been fined over the inappropriate management of bedrails at one of its care homes.