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The future of NHS patient safety investigations – consultation closes 12 June 2018

17 May 2018

The way in which the NHS investigates when things go wrong in order to identify learning and prevent future harm is very much in the spotlight with a number of high profile reports and reviews identifying significant weaknesses in the current system.

The establishment of the Healthcare Safety Investigation Branch (HSIB) in April 2017 is seen as one way to raise the standard of local investigations. At the time of writing, HSIB is in the process of undertaking nine investigations into a range of safety issues and from April 2018, it will also start to investigate a number of serious maternity incidents. The idea is that in addition to disseminating timely learning from these investigations across the NHS, HSIB will also act as an exemplar to improve the quality of local investigations.

Alongside this and to support NHS Trusts at a local level to respond effectively and appropriately when things go wrong, NHS Improvement is looking to revise the Serious Incident (SI) Framework (2015). The consultation, which closes on 12 June 2018, identifies a number of common problems associated with investigation in the NHS including defensive cultures and lack of trust by both patients and families and staff and an inappropriate ‘one size fits all’ use of the SI process to investigate every incident regardless of the complexity or level of harm.

NHS Improvement is seeking views on various changes to the current SI Framework to enable the NHS to respond more appropriately and effectively when things go wrong. It also proposes to realign the SI principles of investigation with the principles used by HSIB to emphasise the importance of a strategic and expert approach to local investigations.

The consultation provides an important opportunity for NHS Trusts to contribute to the debate. Teams involved in local investigations will have an invaluable insight into the various challenges currently faced and it is vital that these views are heard to help shape the future landscape for incident investigation in the NHS. If you are interested in providing a response but would like assistance in collating a submission, please contact Amelia Newbold.

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