Clinical Negligence Solicitors

A report by the independent Expert Advisory Group (EAG) has said there is room for improvement for investigation capability throughout the NHS.

The EAG is advising Health Secretary Jeremy Hunt on the creation of the Healthcare Safety Investigation Branch (HSIB).

The EAG’s advice is that HSIB should set an example to the whole health system on how to undertake learning-oriented safety investigations – helping those in the system to improve, rather than taking on the majority of investigations itself.

The report makes 13 recommendations – ten aimed at the Healthcare Safety Investigation Branch and three for the Department of Health (DoH) and the wider healthcare system.

The recommendations include HSIB being – and being perceived to be – independent and to have this written into its legislation.

The objective of safety investigations must also be to understand the causes of issues that arise, in order to improve systems and prevent future harm – and not to apportion blame or liability.

The EAG recommends that patients, families and staff must be active participants in the process of investigation – and must be engaged with and supported compassionately and respectfully.

Investigations must also be led by experts – and HSIB must publish reports that explain the causes of safety issues and incidents, as well as issuing recommendations for improving patient safety across the system.

HSIB must also promote the creation of a just safety culture – and must provide families and patients with all relevant information relating to their care, reflecting the responsibilities of healthcare providers.

All information collected solely for the purposes of safety investigation must be protected, making sure safety information continues to be provided and has the confidence of healthcare professionals – and safety information must be provided to investigators with the understanding that it will not be used inappropriately.

EAG adds that hiding or interfering with evidence is unacceptable – and should be made an offence.

The recommendations to the wider system include creating a “just culture” taskforce, improving the wider infrastructure of investigation and resolving outstanding and unresolved cases.
The Department of Health has welcomed the report and will give further consideration to the three recommendations made to the wider system and respond in due course.

The DoH has already formed the legal basis for HSIB in the NHS Trust Development Authority Directions 2016.

The recommendations for the HSIB will be considered when the Chief Investigator is in post – expected in summer 2016. In the meantime, NHS England Director of Patient Safety, Dr Mike Durkin, will continue to prepare the new HSIB.

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