Most NHS organisations around the United Kingdom (UK) have a Patient Advice and Liaison Service (PALS) in addition to a process for the reporting and investigation of serious untoward incidents. When patients have concerns about treatment they have received, PALs is often their first port of call.
In March 2015, the Public Administration Select Committee (the Committee) (which was established by the House of Commons in June 2010 to consider matters relating to the quality and standards of administration within the Civil Service) report stated that serious untoward incident investigations within the NHS were “complicated, take far too long and are preoccupied with blame or avoiding financial liability”.** Most involved parties, doctors and patients, would agree that the reports take too long, and are unsatisfactory for all concerned. We have seen fantastic examples of clinicians being appropriately involved in reports which have provided patients with full narratives of what occurred. We have also seen reports which do not address serious issues, or failings, and therefore cannot be used internally to promote learning and avoidance of future mistakes.
The Committee recommended that there should be a new independent patient safety investigation body. The Independent Patient Safety Investigation Service (IPSIS) was borne, but has since been renamed Healthcare Safety Investigation Branch (HSIB). HSIB’s role will be to offer support and guidance to NHS organisations on investigations. Additionally, it will have a budget to carry out some investigations of its own volition. An Expert Advisory Group (EAG) has been established to advise the Department of Health (DOH) and Secretary of State on HSIB’s role. The EAG’s expertise is drawn from members who are part of the Morecambe Bay investigation team, clinical leads at NHS organisations and advocates for healthcare improvement, amongst others.
On 3 June 2016, Keith Conradi was appointed the Chief Investigator of HSIB. Since 2010, Mr Conradi has been the Chief Executive of the Air Accidents Investigation Branch, on which proposals for the HSIB are largely based.
How will HSIB improve how NHS organisations investigate patient safety incidents?
At present, it is proposed that HSIB will carry out around 30 investigations a year with an initial budget of £3.5m in respect of the most serious risks to patient safety.
We hope that HSIB will take full responsibility for setting national standards by which all NHS organisations should conduct investigations. It will need to ‘lead the way’ and show NHS organisations how investigations should be conducted so that patients are provided with sensitive but informed responses to their concerns, without the finger of blame being pointed at individual clinical staff. HSIB will also need to provide strong advice on how lessons learned from investigations should be cascaded throughout NHS organisations to avoid the same mistakes happening again.
Chairman of the Committee, Bernard Jenkin MP, has stated the following in respect of the HSIB:
"We have consistently called for primary legislation to make HSIB fully independent, and to create a credible 'safe space' which will enable the NHS to properly learn from past mistakes. Since we approved this report, it is increasingly evident that the Government has accepted this recommendation”
Peter Walsh, Chief Executive of Action against Medical Accidents (AvMA) has said the following of HSIB:
"We believe that both PACAC and the government are wrong to prioritise the creation of a so-called 'safe space' for health professionals above guaranteeing openness and honesty with patients or their families about their own treatment.
"This would undermine public confidence in HSIB and run against the principle of the newly created duty of candour.
"Of course we do want to see protection of staff who do the right thing, but most health professionals would agree that denying patients access to the truth is no way to do that."
Commentary
It is quite clear that HSIB has a difficult task ahead of it. It will need to conduct investigations thoroughly and swiftly. Additionally HSIB will have to provide detailed but accessible reports so that patients and clinicians alike can reap the benefits of understanding where things could be done differently.
The clinicians will need to feel that they can be entirely transparent about what happened in any given case without the fear of blame. Patients will need to be kept abreast of progress with investigations in a sympathetic but clear manner so that they are assured that their concerns are being taken seriously.
In short, if the HSIB works effectively it will be best placed to reassure all parties that lessons will not only be learnt by those involved, but also shared with others to improve patient care in future.
