Patient safety

Current safety investigation system ‘unsatisfactory and untrustworthy’

The group tasked with advising the government on how to establish the Healthcare Safety Investigation Branch (HSIB) has warned that the current system is failing patients, families and staff in their recommendations for its replacement.

The expert advisory group created to advise the government on creating the new inspection branch said that evidence collected from staff and those harmed by safety incidents pointed to a pattern of delayed, protracted and poor quality investigations.

It also found evidence of healthcare organisations and staff causing additional distress to patients and families by failing to engage with them or even hiding evidence.

The group said that its evidence “points unequivocally to the unsatisfactory nature of the current system: it is seen as threatening by staff; untrustworthy by those affected; and fails to identify many opportunities to prevent future harm”.

The report added that investigations were poorly resourced within individual organisations and did not share their findings across the health service, allowing for other organisations to learn from previous mistakes.

In their recommendations, the advisory group said that the HSIB must be, and be seen as, independent, and this must be written in its legislation, following a recommendation from the Public Administration and Constitutional Affairs Committee.

Its other recommendations included that investigations are led by experts, seek to find out the causes of safety failings rather than apportion blame, and actively and compassionately involve patients, families and staff.

Investigations should also lead to published reports that recommend safety improvements across the system. Finally, the group said that hiding or interfering with evidence in an investigation should be made an offence.

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