The report supports the planned 'safe space' approach to investigating incidents where patient safety has been compromised, as this gives greater confidence to healthcare professionals in alerting authorities to potential safety problems. However, it calls on the Government to reconsider plans that would allow HSSIB to accredit NHS trusts and foundations trusts to conduct internal 'safe space' investigations, citing the likely conflict of interest. Instead, funding of the new body should be sufficient to allow comprehensive investigation, advice and assistance across the health network.
The report further expresses concern about the limited remit of the HSSIB, being restricted to incidents during the provision of NHS services, or at NHS premises. This does not reflect the complex interactions of health and social care services, provided by local government and private providers. HSSIB powers should allow it to investigate all aspects of the care pathway.
Publishing the report, Committee Chair Sir Bernard Jenkin MP commented:
"When serious incidents take place patients have a right to find out what went wrong and staff need to feel that they can be open without being blamed or made a scapegoat. Poor quality investigations fail to address the concerns of patients, breed mistrust amongst health professionals, and do not help to make care safer. Putting the HSSIB on a statutory footing to conduct independent safety investigations will help to address each of these concerns.
Creating a legal ‘safe pace’ where doctors, nurses and anyone else involved in the delivery of care can speak openly is crucial if the health system is to learn from its mistakes. Far from restricting patients from finding out what happened to them, we believe that the ‘safe space’ will help HSSIB to establish facts and identify the underlying causes of the most serious incidents that take place each year. The experience of other safety critical industries such as aviation has shown that ‘safe space’ works.
For too long health professionals have worked in an environment where blame can be part and parcel of investigations and speaking openly could be damaging to career prospects. Establishing HSSIB as a new independent capability will be a key step towards improving the culture in healthcare and will give staff the confidence to speak openly about the challenges they face.
We are concerned, however, that the draft Bill proposes accrediting some NHS trusts to undertake ‘safe space’ investigations. We believe that this is misconceived as only a fully independent body such as HSSIB should be afforded the powers and responsibility of ‘safe space’."
Background and main findings
In 2015, it was estimated that there are 12,000 avoidable hospital deaths every year. More than 24,000 serious incidents are reported to NHS England, out of a total of 1.4 million mostly low-harm or no-harm incidents annually. Major public inquiries into different aspects of healthcare have revealed a system that is slow to detect and learn from mistakes and individuals who have suffered harm feel that the procedures for investigating incidents are over-complicated, ineffective and, in some cases, are designed to protect clinical staff and hospitals rather than discover the truth. At the same time, staff believe that they are unfairly blamed when things go wrong for reasons outside their control.
In order to improve patient safety, the Government decided to establish a new body to conduct patient safety investigations into a small number of incidents, so that the system can learn from common failures, whether in procedures, staffing levels, training or management, or in technology or policy.
At present, there are many pressures which can deter healthcare professionals from alerting the authorities to potential safety problems, or being frank about failings in patient care. A common feeling is that it is not safe or prudent to speak out, despite existing obligations to be open, such as the duty of candour. The Health Service Safety Investigations Body (HSSIB) will conduct its investigations in a ‘safe space’: HSSIB will be prohibited from disclosing the information given to it but will use this information to produce reports making recommendations that will apply not just to the incidents on which the investigation is focused but also across the health service.
A number of witnesses were concerned that the ‘safe space’ would be used to avoid organisations and individuals being held to account for their actions. The Committee listened with great care to these concerns, since suspicion about HSSIB would undermine its effectiveness. Nonetheless, we were convinced by the evidence that the ‘safe space’ will have no effect whatsoever on any information or evidence already available to patients, regulators or the police. HSSIB’s work will be additional to, not a replacement for, the investigations carried out by trusts, professional regulators, the Care Quality Commission and the Health Service Ombudsman.
The Government also wants to improve the quality of local investigations. It proposes that HSSIB accredit some NHS trusts and foundation trusts to undertake ‘safe space’ investigations themselves into other trusts and, eventually, into incidents taking place in their own trust. The Committee considers this idea to be wholly misconceived. It represents too great a conflict of interest for the accredited trusts, compromises HSSIB’s independence from the system it is investigating and would risk damaging confidence in the ‘safe space’ concept itself. The Committee further recommends that this proposal be dropped from the Bill. Instead, HSSIB should be funded to help to improve the quality of the many thousands of investigations that are conducted across the health system through advising, assisting and providing training.
The draft Bill limits HSSIB’s remit to incidents which occur during the provision of NHS services, or at premises where such services are carried out. It also limits HSSIB’s remit to England, as healthcare is a devolved matter. The Committee believes that both of these limitations pose potential problems as they do not recognise the complex interactions of health and social care, private and public healthcare, and the fact that many patients cross borders within the UK to receive aspects of their care under different administrations. The Committee recommends that HSSIB’s remit should be extended to cover all healthcare in England, however funded. Its powers and the protections of ‘safe space’ should be extended, so that HSSIB investigations can analyse all aspects of the care pathway. The Committee also recommends that the draft Bill should be amended to enable reciprocal co-operation arrangements between HSSIB and the devolved health systems, and to give devolved administrations the choice of participating in HSSIB, if they so wish.
To win the confidence of patients, healthcare practitioners and other bodies with responsibility for patient safety—HSSIB had to be, and be seen to be, independent of existing healthcare structures, including the Department of Health and Social Care. The Committee have made several recommendations intended to increase HSSIB's independence, including to reinforce its accountability to Parliament.